Summary - AHICElectronic Health Records Workgroup Meeting

American Health Information Community
Electronic Health Records Workgroup
Summary of the 24th Web Conference of This Workgroup
Wednesday, September 10, 2008

PURPOSE OF MEETING
The purpose of the 24th Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Jonathan Perlin and Lillee Gelinas, was fourfold:
1. To hear presentations related to the EHR WG’s development of “big bang” recommendations to encourage the adoption and use of EHRs in acute care hospitals
2. To review and comment on the EHR WG’s summary materials prepared by the staff of the Office of the National Coordinator on Health Information Technology (ONC)
3. To get an update on progress related to the transition of AHIC to an independent public-private partnership in the private sector (AHIC 2.0)
4. To review a predecisional draft document prepared by ONC staff pertaining to the timeline for the adoption of EHRs by the U.S. health care delivery system
5. The documents used in the presentations to the EHR WG at this conference are available online at http://www.hhs.gov/healthit/ahic/healthrecords /ehr_archive.html.

INTRODUCTORY REMARKS
Dr. Perlin expressed thanks for the contributions of EHR WG members, the expert presenters on EHR systems in acute care hospitals, and ONC staff. Ms. Gelinas then gave an overview of the agenda for the day.

KEY TOPICS
1. Implementation of EHR Systems in Acute Care Hospitals
As background, Ms. Gelinas explained that the EHR WG’s broad charge is to make recommendations on ways to achieve widespread adoption of certified EHRs, minimizing gaps in adoption among providers. The EHR WG’s efforts to date have focused primarily on encouraging the adoption of EHRs by physicians. In the time it has left, the EHR WG is trying to develop “big bang” recommendations that it can pass along to AHIC to encourage the adoption and use of EHRs in acute care hospitals.

The following invited experts shared lessons they had learned to help the EHR WG develop its recommendations pertaining to the adoption and use of EHR systems in acute care hospitals:

Bonnie Anton, RN, University of Pittsburgh Medical Center
Daphne Bascom, Managing Director, e-Cleveland Clinic
Craig Joseph, Epic, Physician, Clinical Informatics
Christoph U. Lehmann, Director, Clinical Information Technology, Johns Hopkins University
Deb Rislow, Chief Information Officer, Gundersen Lutheran Health System
James M. Walker, Chief Health Information Officer Geisinger Health System
David Whiles, Director, Information Systems & Margaret Robinson, Midland Memorial Hospital

Key Themes in the Presentations. Several key themes that emerged from the seven presentations on EHR systems in acute care hospitals:

Vision and Commitment

Enthusiastic support for developing and implementing an EHR system from the hospital’s CEO and other top leaders, as well as from physician champions, is critical.
Any EHR project should be conceived of in terms of process transformation. Technology should be seen as the means to an end (e.g., improving patient care, improving the quality of care, enhancing operational efficiency, improving accuracy in billing, creating new knowledge), not the goal.
Leaders should not underestimate the forces that help maintain the status quo. In planning, leaders should take into account the fact that people experience change differently.
There are both direct and indirect costs (hardware, software, facilities changes, training, workflow, incentives for training) associated with the implementation and use of EHR systems in hospitals. Across a range of hospitals, some with more modest resources than others, costs were not a major obstacle to the implementation of an EHR system.

Design

Involve everybody (e.g., physicians, nurses, support staff) in the selection and design of the EHR system.
Establish a clear document project structure and goals at the outset.
Start the design of tools with reports needed to meet needs such as recording clinical findings and plan of care, supporting clinical decisionmaking, communicating with other members of the clinical team, supporting billing and payer requirements, and providing a defensive tool against lawsuits.
Conceptualize any clinical document up front before spending a lot of time and energy building it in the system. Mock it up and obtain general approval prior to implementation.
Get lots of input before creating templates. Physicians often resist efforts to standardize and structure data collection because they feel they “lose the patient story” with templates.
Use a granular data structure that allows data (e.g., vital signs, allergies, medications, past medical history) to be pulled from previous documents so that they can be modified and used again.

Implementation

Mandate use of the EHR system. A hybrid environment (paper and electronic) exacerbates frustrations.
Provide training and ongoing support for staff before and after the EHR system goes live.
Recognize that the time commitment needed to learn a new EHR system and perform documentation is daunting and that incentives for physicians may be needed to learn and use the system. Some physicians rerecord information available elsewhere in the patient’s EHR, because they are concerned about documentation requirements, leading to “note bloat.”
Have everybody on the care team (e.g., doctors, nurses, respiratory therapists, social workers) participate in the documentation process, so that the final document is a product of the team.
Monitor progress and make changes in the EHR system. Have frequent and realistic discussions about the impact of changes. Use tools such as an online suggestion box so staff can say how to improve system, weekly issues meetings to discuss suggestions and prioritize them), and weekly update emails to notify staff of any changes.

Recommendations to Encourage Hospitals’ Implementation of EHR Systems. At Ms. Gelinas’ request, the invited presenters offered suggestions to the EHR WG about recommendations to expedite the adoption of EHR systems by acute care hospitals:
1. Establish a technical advisory committee to identify and review various documentation requirements from the Centers for Medicare & Medicaid Services, the Joint Commission, professional organizations, and other entities to see whether they are an obstacle to EHR adoption and to recommend changes, if needed. (Note: EHR WG members were asked to email Alicia Morton at ONC to let her know if they had an interest in serving on the proposed committee.)
2. Set up a national clearinghouse with information about evidence-based templates and free-text systems for hospital EHR systems
3. Develop and make available good information about the direct and indirect costs of adopting and using EHR systems in acute care hospitals (e.g., hardware, software, adoption, workflow changes, training, sustainability)

Discussion. It was agreed that ONC staff would draft a set of recommendations based on these suggestions for EHR WG members’ review prior to being submitted to AHIC.

Staff Action Item #1: Draft a set of three recommendations to help spur the adoption of EHR systems by acute care hospitals (documentation requirements, a national clearinghouse for templates and free text systems, and information about the costs of EHR systems in hospitals) that can be presented by the EHR WG to AHIC on November 18, 2008.

2. EHR WG Summary Documents for Presentation to AHIC Dr. Bell
Dr. Bell presented a set of slides summarizing the findings of the EHR WG and dated September 10, 2008, for presentation to AHIC. She asked EHR WG members for comments on a proposed list of recommendations for AHIC 2.0 in a section titled “Opportunities for Future” in four areas: (1) technology, (2) organizational/cultural, (3) financial/ business case, and (4) other.

Discussion. EHR WG members agreed that the recommendations in the “Opportunities for Future” section of Dr. Bell’s document dated September 10, 2008, should be presented to AHIC.

EHR WG Decision #1: The EHR WG approves presenting to AHIC the recommendations for AHIC 2.0 in the “Opportunities for the Future” section of Dr. Bell’s “EHR WG Summary Overview” document dated September 10, 2008.

Dr. Bell indicated that ONC staff would work offline to develop and incorporate additional recommendations related to the adoption of EHRs by acute hospitals, then send out a new slide with all the recommendations for EHR WG members to approve so that the recommendations could be presented to AHIC at its meeting on November 18, 2008.

Staff Action Item #2: Develop and incorporate, in the section of Dr. Bell’s “EHR WG Summary Overview” PowerPoint document titled “Opportunities for the Future,” the EHR WG’s three new recommendations related to the adoption of EHRs by acute hospitals. Then send out the new version of the document for EHR WG members to review and approve so that the EHR WG’s final list of recommendations for AHIC 2.0 can be presented to AHIC at its meeting November 18, 2008.

3. Update on AHIC 2.0 Transition Activities Dr. Perlin and Ms. Gelinas
Dr. Perlin, who is co-chairing AHIC 2.0’s Membership Group, reported that AHIC 2.0 had been incorporated an independent, public-private enterprise on July 17, 2008, and that Laura Miller, formerly Chief Operating Officer of the Veterans Health Administration, had been hired as interim Executive Director. AHIC 2.0’s board members will be announced at the AHIC meeting on September 23, 2008, and AHIC 2.0 will implement an integrated membership and communications plan this fall. Members of AHIC 2.0 are to include representatives of consumers, employers, government and public health, health care providers, health informatics, research, academic health information exchanges (regional/state-level public private partnerships), health plans and other payers, infrastructure and standards (technical), other health entities (pharmacy, labs, device manufacturers), quality, and vendors/consultants (supply chain).

Ms. Gelinas, who is co-chairing AHIC 2.0’s Transition Planning Group, reported that this group has been developing recommendations based on the recommendations it received from the various AHIC workgroups. The Transition Planning Group’s recommendations will include (1) a prioritized list of transition activities for the initial year of AHIC 2.0’s operations and (2) a complete list of transition activities, including those best taken on by other entities (including the Federal Government or a Federal Advisory Committee). Its recommendations may also include sample organizational model(s) for AHIC 2.0 to use to continue advancing these important activities or a sample level of effort for the AHIC 2.0 to consider when setting up operations to include AHIC Workgroup transition activities.

Discussion. Dr. Bell asked EHR WG members whether they thought that the EHR WG had met its charges and no longer needed to exist or thought instead that some type of EHR WG or steering committee focused on EHRs for health care providers should continue. Noting that October 9, 2008, is a Jewish holiday, Ms. Gelinas suggested that the EHR WG cancel its October 9 meeting and recommend to AHIC 2.0 that it establish a technical advisory committee that could be folded into AHIC 2.0. Dr. Juhasz said he thought the EHR WG should maintain some sort of structure to make sure that the things it had proposed (e.g., e-prescribing) continued to move forward.

EHR WG members reached a consensus, first, that ONC staff would cancel the EHR WG’s October 9 meeting and, second, that ONC staff would consult with EHR WG members about their availability and schedule a very short EHR WG meeting for the last week of October or first couple of weeks of November to review and approve the EHR WG’s recommendations for AHIC 2.0 so that they could be presented at the AHIC meeting on November 18, 2008.

Staff Action Item #3: Send an email to EHR WG members canceling the planned EHR WG meeting for October 9, 2008. Check EHR WG members’ availability, and then schedule a short EHR WG meeting in late October or early November prior to the AHIC meeting on November 18, 2008.

4. Predecisional Draft Timeline for Adoption of Interoperable EHRs by the Health Care Delivery System Dr. Bell
Dr. Bell gave an overview of a document that she had prepared titled “Pre-Decisional Draft: Timeline for Delivery System Adoption,” dated September 10, 2008, noting that the plan was to present a final version of the document to AHIC at its meeting on November 18, 2008.

Dr. Bell explained that the slide titled “Adoption of Interoperable EHRs by the Delivery System” specifies a goal of 50 percent adoption of EHRs by 2014. AHIC’s Chronic Care Workgroup had already recommended that reimbursement reform in that slide begin earlier than 2011. She explained that the slide titled “Consumer-Centric Health” specifies a goal of 20 percent patient engagement with health information exchange by 2014.

Dr. Bell asked EHR WG members to email her their comments on the draft, so that she could revise it and bring it back to the EHR WG members for their review and approval at the very short EHR WG meeting now being planned for in late October or early November 2008. Ms. Gelinas made some comments (e.g., add a legend to clarify color coding, possibly put an asterisk with things that go back to the presentations the EHR WG had, note that President Bush’s executive order ends at 2014).

Staff Action Item #4: Use EHR WG members’ emailed comments on Dr. Bell’s PowerPoint document titled “Pre-Decisional Draft: Timeline for Delivery System Adoption” dated September 10, 2008, to revise the document so that EHR WG members can approve a final version at the EHR WG’s short meeting in late October or early November 2008.

CONCLUDING REMARKS
There were no public comments. Dr. Perlin closed the meeting by saying that as we look at the challenges we face as a country in terms of Medicare and in terms of the international competitiveness, we cannot afford not to move to EHRs. He added that it is his hope that AHIC 2.0 will help continue, and even accelerate, the adoption of information technology toward improving the safety, quality, and the efficiency of care.

The next AHIC meeting will be September 23, 2008. The EHR WG’s meeting scheduled for October 9, 2008, will not be held. Instead, a shorter meeting of the EHR WG will be scheduled for late October or early November to prepare for the AHIC meeting on November 18, 2008.

SUMMARY OF DECISIONS AND ACTION ITEMS

Staff Action Item #1: Draft a set of three recommendations to help spur the adoption of EHR systems by acute care hospitals (a technical advisory committee to review documentation requirements, a national clearinghouse for templates and free text systems, and information about the costs of EHR systems in hospitals) that can be presented by the EHR WG to AHIC on November 18, 2008.

MEETING MATERIALS
Agenda
DRAFT Meeting Summary (May 21 2008, Meeting)
Presenters’ slides:

Bonnie Anton, Electronic Order Set Coordinator, University of Pittsburgh Medical Center, St. Margaret Hospital
Daphne Bascom, Managing Director, e-Cleveland Clinic, Cleveland Clinic
Craig Joseph, Epic
Christoph U. Lehmann, Director, Clinical Information Technology, Johns Hopkins Children’s Medical and Surgery Center and Assistant Professor in Pediatrics & Health Sciences Informatics, Johns Hopkins University
Deb Rislow, Chief Information Officer, Gundersen Lutheran Health System
James M. Walker, Chief Health Information Officer Geisinger Health System
David Whiles, Director, Information Systems & Margaret Robinson, Midland Memorial Hospital

EHR WG Summary Overview September 10, 2008
AHIC Transition Update September 8, 2008
Predecisional Draft: Timeline for Delivery System Adoption September 10, 2008

Electronic Health Records Workgroup
Members and Designees Participating in the Web Conference


Co-chairs
Lillee Gelinas	Veterans Health Administration, Inc.
Jonathan Perlin	Hospital Corporation of America

Office of the National Coordinator for Health Information Technology Staff
Karen Bell
Alicia Morton

Members and Designees
Samantha Burch (for Charles Kahn)	Federation of American Hospitals
Nahn Do	Department of Defense
Peter Elkin	Mount Sinai School of Medicine
Linda Fischetti	Veterans Health Administration
Robert Juhasz	American Osteopathic Association
Mike Kappel for Pam Pure	McKesson
Jason Kreuter	American College of Cardiology
Debbie Mikels (for Blackford Middleton)	Partners Healthcare System

Presenters
Bonnie Anton	University of Pittsburgh Medical Center
Daphne Bascom	Cleveland Clinic
Craig Joseph	Epic
Christoph Lehmann	Johns Hopkins University
Deb Rislow	Gundersen Lutheran Health System
James M. Walker	Geisinger Health System
David Whiles	Midland Memorial Hospital

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.