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American Health Information Community

Electronic Health Records Workgroup

Summary of the 17th Web Conference of This Workgroup

Friday, July 20, 2007

PURPOSE OF MEETING

The purpose of the 17th Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Jonathan Perlin and Lillee Gelinas, was twofold: (1) to hear testimony from three institutions about their experiences with the adoption of health information technology (HIT) in hospital inpatient settings and (2) to continue planning related to the EHR WG’s activities and the AHIC use cases.

INTRODUCTORY REMARKS

Dr. Perlin, after opening the meeting at 1:00 p.m., welcomed all of the new members of the EHR WG who will be participating in the EHR WG’s efforts related to the inpatient adoption of HIT. He then asked the members present to introduce themselves. The minutes of the May 22, 2007, EHR WG meeting were approved. Dr. Karen Bell observed that when AHIC was created in 2005, its initial charter specified that AHIC would be modified to operate as a public-private entity in the private sector after a period of time. She stressed that although planning for this transition has begun, it will not reduce the commitment to the work to be done by the EHR WG.

KEY TOPICS

1. Presentations on Inpatient Adoption of HIT

The representatives of three institutions that have been extraordinarily successful in moving from paper-based records to HIT in inpatient hospital settings, namely Vanderbilt Medical Center, Geisinger Health System, and Midland Memorial Hospital, shared key lessons learned from their experiences.

a. Vanderbilt Medical Center Dr. William Stead, Associate Vice Chancellor for Strategy & Information and Chief Financial Officer

Vanderbilt Medical Center is an academic medical center in Nashville, which has been implementing HIT for about 16 years. Dr. Stead shared five important lessons from Vanderbilt’s experiences. First, the central issue to be grappled with is how to improve decisions about healthcare and build the systems to improve healthcare, not how to adopt HIT. HIT cannot be simply inserted in the old way of practice. Its greatest efforts go into redesigning practices around evidence-based systems of care. Second, the movement toward systematic medicine is not a destination but a journey requiring iterative and continuous evolution of peoples’ roles, processes, and technology. Vanderbilt Medical Center began with data-driven pathways in 1989, and then moved to work on physician order entry in 1994, to an electronic patient chart in 1996, and finally to proactive quality improvement. Third, in a process of iterative improvement, the technical approach is important. Most existing HIT systems use techniques developed in data processing and automation and are designed to work at a microsystem level. More effort should be put into using HIT and electronic health records (EHRs) to work at the macrosystem level (e.g., the way that Google works). Fourth, most of the work in implementing change processes and adoption occurs outside an institution’s IT department. Fifth, the financial returns from HIT are not straightforward. Dr. Stead identified three categories of return on HIT: (1) things that result in a direct and quantifiable improvement to the bottom line; (2) things that improve productivity but affect the bottom line indirectly in ways that are not easily quantified, either because they involve parts of a full-time equivalent position or something in which there is no clear way of measuring the impact on productivity; and (3) better management choices, improved long-term outcomes, the right as opposed to necessarily the most profitable use of profit centers, the right transparency, and patient engagement. Dr. Stead and his colleagues at Vanderbilt Medical Center try to get financial returns in the first category to pay for the gains in the third category.

Discussion. Dr. Perlin asked whether Dr. Stead believed specifying a specific date for certain milestones in hospital inpatient settings would be helpful. Dr. Stead said yes, he thought it would be helpful to specify a date certain for measuring quality goals that everyone agrees can have an impact.

b. Geisinger Health System Dr. Jim Walker, Chief Medical Officer

Geisinger Health System is a health system spanning 40 counties of central Pennsylvania, four hospitals, 41 clinics, and 670 physicians. Over the past 12 years, Dr. Walker and his colleagues have led Geisinger Health System to develop organizational capabilities (including the capability for workflow analysis and redesign) and incentives for dramatic changes in healthcare processes using HIT. Leadership has been critical to this endeavor. Physician and non-physician champions view HIT not as an end in itself but as a tool that can be used to transform and improve the care the health system provides (e.g., improve reimbursable performance, improve patient experience, facilitate safe and effective processes, decrease the unit cost of care, improve employee satisfaction). Trying to implement HIT all at once proved to be a fiasco. For that reason, HIT was implemented in phases, beginning with lab results and e-mail, followed by documentation and order entry, and then other capabilities once the staff had improved their skills and experienced the power of the technology. To spur the adoption of new processes, Geisinger Health System provides financial and other incentives for individuals, managers, and HIT teams to provide higher quality, or affordable quality care. Dr. Walker and his colleagues believe that “you get what you pay for,” so they provide incentives for quality rather than for HIT.

Discussion. In response to questions, Dr. Walker noted that the advantages that Geisinger Health System has in terms of using HIT to transform care processes in inpatient settings may not be reproducible elsewhere. Geisinger Health System’s leaders have worked together for a long time, and the institution is remarkably collegial and free of turf warfare. The system is large enough to be able to contemplate using HIT to transform care processes and has a region that it feels responsible for. Dr. Walker believes that most small hospitals lack the capacity to create processes and EHRs that are effective in improving quality, decreasing costs, and maintaining safety. He believes it is important to figure out ways for organizations such as Vanderbilt and Geisinger to share what has been developed and share methods of providing incentives to keep the systems current and improve their capacity.

c. Midland Memorial Hospital Margaret Robinson, Vice President for Patient Care Services & David Whiles, Director of Information Technology

Midland Memorial is a 320-bed, nonprofit community hospital in Midland County, Texas, 250 miles between Dallas and El Paso, and is the sole provider in the area. It is the first hospital that has successfully adapted and deployed for its own needs an open-source version of the VistA EHR developed by the VA. Midland Memorial’s experience with HIT began in 2002, when the hospital decided to implement a hospital information system based on the open-source VistA to avert a financial crisis. Partnering with a small consulting firm in California called Medsphere, Midland developed its own HIT system known as Electronic Data and Information Technology for Health Care (EDITH).

The biggest challenge in developing EDITH was looking at all processes and trying to imagine what they would be like in an electronic system. The time commitment and effort required to customize and implement EDITH was daunting, but the system has enabled Midland Memorial to enhance patient safety, support quality initiatives, give physicians better information, and make a contribution to the healthcare industry. For three years, Midland Memorial has won VHA, Inc.’s leadership award for clinical excellence. Midland Memorial’s experience underscores the importance of identifying long-term goals, then stepping back and figuring out how to proceed. Different stakeholders (e.g., IT people, physicians, nurses) view the medical record differently, and their perspectives had to be taken into account. Midland phased in the implementation of EDITH, beginning with pharmacy in October 2005; following with lab entry, order entry, clinical documentation, and bar code medication administration; and then transitioning to a full EHR in February 2007. Conversion was challenging for staff, especially when there were both paper and electronic records. To get physician buy-in, Midland Memorial gives physicians remote access to the EHR from home and pays them for time they need to get familiar with EHR if they demonstrate they are using it. The original VistA project budget, with no cost for software, was about $7 million. Since embarking on the project, Midland Memorial has found additional applications and needs for the system, so the amount spent now exceeds that.

2. Planning of EHR WG Activities and AHIC’s 2008 Use Cases

The EHR WG discussed the following three topics: (1) the process by which the EHR WG would obtain public comments on its recommendation to AHIC tying physicians’ reimbursement to EHRs (Recommendation 4.0); (2) the AHIC Director’s request for feedback on AHIC’s 2008 use cases before the AHIC meeting on July 31, 2007; and (3) setting the EHR WG’s plans and priorities. Dr. Bell noted that the EHR WG would not be meeting again until September 25, 2007, because there was no quorum for the meeting scheduled for August 14.

a. Process for Obtaining Public Input on EHR WG’s Recommendation 4.0

At the AHIC meeting in April 2007, the EHR WG was advised to get much more public input on its Recommendation 4.0 related to implementing differential reimbursement to physicians for use or nonuse of EHRs. Dr. Bell suggested that the most effective and efficient way to elicit public comments on the recommendation in August, given that the EHR WG would not be meeting that month, might be for ONC staff to put a notice in the Federal Register seeking public comment on the recommendation . ONC staff could then bring public input on the proposed recommendation to the EHR WG’s next meeting on September 25.

EHR WG members expressed support for the process suggested by Dr. Bell, with the understanding that Office of the National Coordinator (ONC) staff would publicize the process widely to make it succeed. Dr. Bell stated that ONC staff would do whatever it took to get sufficient public input. It was agreed that ONC would make sure the process would be announced at the July 31 AHIC meeting and that ONC staff would reach out to organizations and the industry press to bring the opportunity for public input to their attention.

Staff Action Item #1: Publish a notice in the Federal Register soliciting public comments on the EHR WG’s Recommendation 4.0 related to tying reimbursement to EHRs. Ensure that the opportunity for public comment on this recommendation is widely publicized. Report on public feedback obtained at the EHR WG’s next meeting on September 25, 2007.

Status #1: No public input elicited by ONC. Dr. Bell to update status during 9/25 WG meeting.

b. Planning for AHIC’s 2008 Use Cases and Use Case Prioritization Process Ken Gebhart, BearingPoint

Mr. Gebhart briefly updated EHR WG members on activities related to the development of past, present, and planned AHIC use cases, referring to a chart prepared by Dr. John Loonsk at ONC. That chart lists the seven use cases completed or underway in 2006 and 2007, six possible use cases for 2008, and a lengthy list of unmet needs for use case development in 2009 and beyond.

Mr. Gebhart called EHR WG members attention to a recent email from AHIC Director Judith Sparrow asking them for their input on the six use cases for 2008: (1) remote monitoring, (2) remote consultation, (3) referrals and transfer of care, (4) personalized healthcare, (5) public health case reporting, and (6) response management. Mr. Gebhart and his colleagues will be synthesizing the feedback for discussion at the upcoming AHIC meeting on July 31, 2007. HHS Secretary Mike Leavitt and AHIC are pushing to get these use cases done this year, so that they can be published in 2008. The AHIC use case on referrals and transfer of care may be of particular interest to the EHR WG. Mr. Gebhart also asked the EHR WG to reexamine and revise the list of unmet needs for use case development in 2009 and beyond. Finally, Mr. Gebhart asked for feedback on the set of criteria used in the January AHIC process for prioritizing the follow-on use cases.

c. Planning for Future EHR WG Meetings

Originally, it had been hoped that the EHR WG could discuss priorities among five focus areas related to the adoption of HIT in hospital inpatient settings (financial and business case, organizational and cultural, technology, legal and regulatory, and privacy and security) and planning for future EHR WG meetings. There was very little time for this discussion, so it was agreed that the discussion would have to be continued online and at subsequent meetings. Organizational and cultural issues had been highlighted as important considerations in the presentations during this meeting, and Dr. Bell suggested that the EHR WG begin looking at these issues at its next meeting on September 25, 2007. Dr. Perlin agreed that this was a good idea.

Staff Action Item #2: Continue the discussion of EHR WG priorities and plans. Plan to focus on organizational and cultural issues related to the adoption of HIT in hospital inpatient settings at the September 25, 2007, EHR WG meeting.

Status #2: September 25th meeting will feature a workforce panel discussion.

Dr. Bell announced that the next EHR WG meeting would be from 1:00 to 4:00 p.m. on Tuesday, September 25, 2007. There were no public comments, and Ms. Gelinas closed the meeting at 3:50 p.m.

SUMMARY OF ACTION ITEMS

Staff Action Item #1: Publish a notice in the Federal Register soliciting public comments on the EHR WG’s Recommendation 4.0 related to tying reimbursement to EHRs. Ensure that the opportunity for public comment on this recommendation is widely publicized. Report on public feedback obtained at the EHR WG’s next meeting on September 25, 2007.

Status #1: No public input elicited by ONC. Dr. Bell to update status during 9/25 WG meeting.

Staff Action Item #2: Continue the discussion of EHR WG priorities and plans. Plan to focus on organizational and cultural issues related to the adoption of HIT in hospital inpatient settings at the September 25, 2007, EHR WG meeting.

Status #2: September 25th meeting will feature a workforce panel discussion.

MEETING MATERIALS

Agenda

Presentations:

Background Material:

Electronic Health Records Workgroup

Members and Designees Participating in the Web Conference

Friday, July 20, 2007

Co-chairs

Lillee Smith Gelinas

VHA, Inc.

Jonathan Perlin

HCA, Inc.

Office of the National Coordinator for Health Information Technology Staff

Karen Bell

Alicia Bradford

Judith Sparrow

Members and Designees

Bonnie Anton

University of Pittsburgh

Gail Arnett (for Jack Price)

Healthcare Information and Management Systems Society

Laura Cranston

Pharmacy Quality Alliance

Andrea Delmotte

American Nurses Association

Nhan Do

Department of Defense

Peter Elkin

Mayo Clinic

Linda Fischetti

Veterans Health Administration

Robert Juhasz

American Osteopathic Association

Howard Isenstein (for Charles Kahn)

Federation of American Hospitals

Mike Kappel (for Pam Pure)

McKesson

Robert Smith

Veterans Health Administration

Disclaimer: The views expressed in written conference materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of HHS; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.