American Health Information Community
Electronic Health Records Workgroup #24
Wednesday, September 10, 2008

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.

>> Judy Sparrow:

Good afternoon and welcome, everybody, to the 24th meeting of the Electronic Health Record Workgroup. Just a reminder: Again, this is a Federal Advisory Committee, which means it is being broadcast over the Internet, and there will be an opportunity at the close of the meeting for the public to make comments. Workgroup members on your telephone lines, please remember to mute your phones when you’re not speaking and identify yourselves as you begin to speak.

On the phone today, we have one of the Co-chairs, Jonathan Perlin from HCA Healthcare; Karen Bell from ONC is on the phone; Bonnie Anton from the University of Pittsburgh; Nhan Do from the Department of Defense; Linda Fischetti from Veterans Health Administration; Debbie Mikels and Jackie Raymond from Partners HealthCare; Mike Kappel from McKesson. And we do have our speakers. Most of them are on the telephone line. And here in the room, we have...

>> Lille Gelinas:

Lillee Gelinas. Hello, everyone.

>> Jason Kreuter:

Jason Kreuter, American College of Cardiology.

>> Alicia Morton:

Alicia Morton, ONC.

>> Cinyon Reed:

Cinyon Reed, ONC.

>> Judy Sparrow:

Did I miss anybody on the telephone line?

>> Peter Elkin:

Yes, Peter Elkin from Mt. Sinai School of Medicine.

>> Judy Sparrow:

Great. Thank you, Peter. And with that, I’ll turn it over to the Co-chairs, Dr. Perlin and Lillee Gelinas.

>> Lillee Gelinas:

Jon, you want to welcome everyone and then I’ll take it over for the agenda?

>> Jonathan Perlin:

Terrific. I think I really do appreciate everyone who’s joining today. This is a particularly important meeting. We have a very full agenda, as I’m sure you realize. And I would express my appreciation to each of the presenters who will walk through their experiences with the acute care documentation in hospitals, something that, you know, I think this discussion demonstrates is not aspirational conceptually or conceptual, but something that really need to be an aspiration that’s realized for acute care and nationally. And so, their insights will be particularly valuable.

So I want to thank Dr. Karen Bell, Alicia Morton, and Kate Team for putting together a document that summarizes both the testimony that the Working Group has received over the past 24 meetings hard to believe that many have transpired as well as the consolidation of that information to recommendations to the AHIC and accomplishments in support of both the broad and narrow charge as well as the use cases. With that, let me turn back to Lillee, and we’ll go begin to go through the agenda.

>> Lillee Gelinas:

That would be great. And thank you, Jon. As Judy and Jon both teed up, this is our 24th meeting. And just to refresh your memory, we have made 38 recommendations to the AHIC and as a reminder that our broad charge is to make recommendations on ways to achieve widespread adoption of certified EHRs, minimizing adoption gaps in providers. As you know, we’ve spent the majority of our time in the physician sector, and we wanted to devote at least what remaining time we had to adoption in the hospital sector.

We have some important recommendations in this agenda to review and get consensus around, as well as important updates. And I just want to make sure everyone is very closely centered on what it is that we have to do today. We really would like to see the Big Gang recommendation for hospital adoption come out of this Group. In order to do that, we have an elite panel of many highly informed organizations and experts who understand acute care documentation implementation in hospitals. And we’ll hear from that panel. We’ll then consider what they have told us and see if there’s a recommendation that would come out of this Group. We also need consensus around our Workgroup summary all of our work. It’s hard to believe that we’re close to being sunsetted, but we need to make sure there’s consensus about what we’ve accomplished as well as what will transition to AHIC 2.0. The other piece that’s an update for this Group will be the update where Jon Perlin, Dr. Bell and myself will try to answer any questions you have about where we are in the formation of the AHIC successor and then finally the timeline for delivery system adoption that’s also an important part of what we will transition.

So we do have a packed agenda. And as a way of teeing up what we’re going to accomplish, I just want to remind everyone that despite enormous efforts of the Office of the National Coordinator, the American Health Information Community, this Electronic Health Records Workgroup, and Secretary Leavitt, there’s still only 11 percent of hospitals in America that have full adoption of electronic health records. And therein lies the challenge. We’ve assembled an elite panel to help us consider the whys of the situation and the “So what?” of the situation going forward.

I would ask each of the panel members, since they only have 10 minutes and we will interrupt you at the 10-minute mark, so please understand what you’re going to accomplish the most important thing that you want to impart to this Workgroup, in terms of what you’ve learned in electronic health record implementation and what would be germane around a recommendation that we could propose for the future. So it’s not your story. We heard from many of you in terms of your story in the past. We really are very interested in what your recommendations are.

We are using a big speaker phone here in our room, and we will really try to keep paper shuffling to a minimum. I will tell you, when I’m on the other end of the line, I hear paper shuffling more than voices. And we’ll try to be respectful of that so that our speakers’ words will come through.

So I really do want to join Jon here at the top of this call in saying that this work as it comes to a close, I have to tell that you working with Jon Perlin has been one of the highlights of my professional career, as well as the tremendous members of this Workgroup and the Office of the National Coordinator staff. And it’s just really hard to believe that we’re on the downslope of what has been very robust and important work. So staff, Workgroup members, and Jon, I just really wanted to honor you here at the top of this call.

>> Jonathan Perlin:

I would be remiss if I didn’t acknowledge both Office of National Coordinator staff and Lillee Gelinas’s terrific, inspiring leadership. And it’s going to take really terrific and inspiring leadership on everyone’s point, which makes the subject of this matter so the matter of this call so critical if we’re to realize that vision of really supporting safe, effective, efficient, and compassionate health care that we know can be achieved through electronic health records in the shortest time possible. Lillee, do you want to just check on a review of the minutes and then we’ll move forward?

>> Lillee Gelinas:

Yeah, that works for me. Judy, do we have a quorum?

>> Judy Sparrow:

Yes.

>> Lillee Gelinas:

We do have a quorum? You have in front of you, in your packets, the minutes of the May 21 Electronic Health Records Workgroup. That was our 23rd Web conference. Are there any additions or corrections? (Pause) Okay. Hearing none, I declare consensus, and the minutes are approved.

We’re going to begin our Acute Care Documentation Panel with Bonnie Anton from the University of Pittsburgh Medical Center. Bonnie, I’ll turn it over to you, and you’ll have your full 10 minutes. Thank you.

>> Bonnie Anton:

Thank you very much. It’s great to have this opportunity for us to all get together and talk about what is important to each of us in our own hospitals, in terms of acute care documentation. And I think what I’d like to do today is look at it from the perspective of a community hospital. And will these slides go on?

>> Lillee Gelinas:

Just say, “Next.”

>> Bonnie Anton:

Okay, ne okay, thank you. I had this slide up just to give you some information about the people who were involved in planning this presentation in addition to myself: Melanie, our Director; and Kelly, our Training Specialist. Next.

I’d like to give you a little bit of idea of what the University of Pittsburgh Medical Center St. Margaret Hospital is. It’s a 250-bed community hospital acute care and teaching hospital. We have approximately 800 primary care and specialty physicians 1,500 clinical support staff members. We have an RN program. We have an LPN program. And we are one of 19 hospitals in the UPMC system. Our other hospitals various hospitals are in different phases of implementation of the electronic health record, in terms of CPOE and documentation.

In 2004, the Univ St. Margaret’s Hospital implemented the electronic health record. And we went the Big Bang effect. And we have very little on paper at this point. Our MDs all use CPOE. And just as a means of what we use, we do have Lucerner as our vendor. And all our clinical staff document electronically. Next.

To give you an idea of the size, in 2007, we had a little over 14,000 inpatient admissions, 253 outpatient visit 253,800 outpatient visits, 37,000 ED visits, and 12,000 a little over 12,000 surgeries. Next.

How I choose to present my information is that I really want to look at what were the successful components of our implementation and, since we’ve been live in 2004, what kind of lessons have we learned. And I think when you look at what’s one of your most successful influences, I truly feel the information on this slide is of paramount importance, in terms of your CEO, CNO, CIO, physician champion, and clinician’s input. And when I talk about CEO and CNO input, I’m not talking about just “Okay, let’s agree to use this system, let’s agree to send use this vendor, and let’s sign on the dotted line.” No, I’m talking about ongoing support, and I’m talking about active ongoing support, in that there are regular meetings with the CIO and our physician champion and our nursing representation to see what problems are arriving arising.

In terms of physician champion, there’ve been he’s been very, very helpful to us. If we have an issue with a physician who maybe is not using the electronic health record correctly say, for instance, putting in too many orders by free text all we do is, from our reports, we find this out; we contact our physician champion; he directly contacts that physician and speaks to him or her; and if that is not effective, then it goes to the CEO, and the CEO directly talks to this physician. This is also true with the CNO, in terms of any issues we have with clinical documentation, as well as any supervisory, ancillary staff members. So this is what I mean by when I say “administrative support.” It is ongoing, and it’s just not on paper, so to speak. Next slide, please.

When we look at what influences success, one of the things I put up here is reports. In other words, we can run reports based on what we’re actually looking for. Are we looking to see what kind of documentation is done for smoking cessation or patient education components? And it’s really important because of when we look at the CMS initiative, Leapfrog, Joint Commission in our situation, we have some HighMark initiatives that we must meet. And we’re looking for pay-for-performance. We need to know why they’re not being done.

And this by this way, we can get reports. We can find out what the what staff is not documenting patient education. For instance, it’s very important when you have congestive heart failure patients that there are seven components for patient education that must be documented, five components for stroke. And if one of those are not documented is not documented on, we fall out. And as a community hospital, our numbers for admissions might not be that great for that month, so we our numbers cannot look good for that month based on why something that was not documented correctly.

The same thing goes with our order sets that are developed in house. For instance, for congestive heart failure patients, it’s required that they’re be on the beta blocker or ace inhibitor. If they are not, you must document why they’re not. So we have it built into our order sets all the various reasons why they might not be on it. And we can run reports as to why the patient may have is not on the beta blocker, and it should have been documented why they weren’t.

We have visual reminders on our EMR. For instance, for the Joint Commission, when a patient is given a pain medication, depending on what medication it is, 30 minutes afterwards or an hour afterwards, you are required to reassess the patient and document the effectiveness of the medication. This appears on the EMR as a beautiful, big, red box. And when you click on it, it opens the form up, and there’s required fields that must be filled out at to so that you can close the form.

We also have a report that can run periodically to find out how many of these reminders were not addressed and who did not address them. We have an online suggestion box where staff any staff can go in and make suggestions as to how they think the system could be improved and be more efficient. We have weekly issues meetings where we discuss various suggestions and prioritize them. Some of them are very high priorities patient safety. Some are just, you know, some tweaks in terms of a form. We’d like to have some small component added to this form. And then some are some things that, gee, would be nice to have. So we can prioritize that.

We have weekly update emails that we notify the staff of any changes. And I put hardware on here, because I think it’s a very, very strong influencing factor. On our units, each of our rooms have a computer insi at the bedside. We find they’re not being used very often, because the staff for instance, if the nurse has 5 patients, she has to go into that particular room, log on, document, come out, go to the next room, log on. She chooses to use she or he chooses to use the workstation on wheels. And that way, she does not have to document each time.

We also, of course, have the computers in the nurse’s stations. And in the morning, it’s very, very interesting how it’s difficult to find a computer if you walk on some of the units. And it’s interesting what some of the issues are that patients find or the staff use. We found that when nurses are used for instance, a resource nurse gets called away from her desk and her computer. Obviously she’s going to be logged off, and somebody else can come and sit there and use her computer. When she comes back, you know, it’s in use. Well, we found out what some of the nurses do is, they shut off the monitor. So

>> Lillee Gelinas:

Bonnie, excuse me. You’re at the 1-minute mark. If you wouldn’t mind summarizing what your primary learning and recommendations

>> Bonnie Anton:

Okay.

>> Lillee Gelinas:

Thank you.

>> Bonnie Anton:

Next slide. Next okay. Contributing factors big thing with training and education cultural change. We have to look at work floor process change and have the physician involved in it. Second next slide.

Some of our issues are the turnaround time for getting changes involved if the clinicians want education instances. We get a lot of residents who have been to the VA, and they love the VA system. They’re intuitive. Their documentation is fantastic. They come to us, and they say, you know, “I can document electronically,” and then they find out that our system’s a little bit different, even though they think the world of the VA system. Periodic upgrades can be an issue for the staff. Next slide, please.

Summary: I would not want to work in a hospital that does not have electronic documentation. I think this is very important with our mobile society, with staff going from hospital to hospital across the country. They’re coming into hospitals saying, “I’m used to this; this is what I want.” This is what’s going to influence and hopefully change this 11 percent. I’ve never been so organized so early in my shift, and nurses have said, “If I’d known there was going to be a downtime this weekend, I would not have volunteered to work.” And we’ve had physicians during a downtime, when we go to paper, actually refuse to write their orders on paper. And these are physicians who were kicking and screaming when we initially went with our implementation. Thank you.

>> Lillee Gelinas:

Bonnie, that I know that was quick. And when we come to the summation portion, what type of recommendations should this Group recommend be thinking about your lessons learned here?

>> Bonnie Anton:

Right.

>> Lillee Gelinas:

Because you’ve had tremendous experience in this area, and we have much to learn from you.

>> Bonnie Anton:

Thank you.

>> Lillee Gelinas:

Thank you. Let’s move now to Dr. Daphne Bascom, who is the Managing Director of the e-Cleveland Clinic. Dr. Bascom, take it away.

>> Daphne Bascom:

Thank you very much, and I appreciate the opportunity. In the interest of time, could we go straight to Slide 12? And I can summarize the previous slides very briefly. Again, thank you.

And just to give you a brief background on the Cleveland clinic health system, we’re a 13-hospital health system in Cleveland, OH, in the northeast, with about 3 million total patient visits annually, 5,000 (inaudible) physicians; and have been live on a standardized electronic health record across our system which is epic, and we call it MyPractice for approximately 6 years. Our strategy has been to begin in the ambulatory setting, and so we are just now in the interesting period of beginning our implementation across our main campus and regional hospitals of our inpatient electronic health record. And despite all of our experience, sometimes I think this slide very succinctly describes where we think we are, and it has definitely been a journey. Next slide, please.

So the purpose, in my mind, for clinical documentation is in part communication, is in part communication, and is in part communication. So we are having a dedicated focus on ensuring that we have a comprehensive plan of care. And it is a struggle. But we are trying to use our clinical documentation as a driver for better interdisciplinary communication, better interdisciplinary documentation and subsequent to that #1 edict, all of these other purposes of clinical documentation are additional drivers. Next slide, please.

So as we transition into this electronic world, there were many clear reasons why we wanted to move to electronic practice, some of them being the incoherent writing of many of our providers. Next slide, please. But the other drivers for online physician documentation were centered around patient safety, workflow, and also transitioning to a paper-light organization. So we do have a very active patient safety institute. And part of what we’re trying to do in developing a practice model that makes patient safety as a key component of that is ensuring that we have ubiquitous access at all care settings. We are improving our legibility. You’re having some structured data collection. And the other key component that we have begun to address is that we do have an open medical record, and so we have made an opportunity for patients to request access to their records on paper and are implementing a plan to do that electronically. So again, this will help facilitate engaging the patient in part of their care. Next slide, please.

The other thing is that what we found after having implemented an ambulatory record is that you begin to have a slow creep of providers finding ways to document on the inpatient record. And some of them became very creative. And so it became very clear that we needed to put structure around it. Next slide, please.

So beginning early this year, we actually began to scope a clinical documentation project on the inpatient setting. We tried to begin our focus around some services that had begin early adopters for CPOE, and with the thought that this might complete their clinical workflow within the electronic health record. And our goal was to transition to incorporate the rest of the campus with our main CPOE rollout, which occurred this May of 2008. We also wanted to take this opportunity to begin to develop some standardized tools around a systemwide H&P consult note, progress note those common notes that everyone needs to write and which off of which we can drive many key communication, core measures, standards of care, present on admission so incorporating enterprise-level objectives with a with our care model. Next slide, please.

So content design is key. And you need to start out almost by figuring out where you want to go, because if you don’t have a clear destination, the path that you take getting there can be very circuitous and problematic. Next slide, please.

The other thing is that the training and rollouts are also critical, though we did have a multifac multipronged training approach, whether it was one-on-one training, training incorporated with the CPOE, department-level training but from a high level, there needs to be some clear mandate would be my recommendation: Training is required, because as Bonnie said, people think they know how to document, but if you really begin to drill down into the quality of our documentation, we have developed some bad practices on paper that can translate and become magnified in the electronic world. Next slide, please.

So the success factors are key. The patients seem to love it. We are getting providers to the point where they don’t dislike it. But there is some improvement in efficiency. Legibility is definitely improved. And the fact that people can access the record in the green chart, which is our paper chart is not tied to that patient, whether they’re off the floor, whether someone else has it has been a big win. And we’re also are beginning to see some indirect financial ramifications from our implementation. Next slide, please.

But we’ve also identified several unintended consequences. And this would be my main message to the Group: that you need to clearly understand the operational, functional, and content quality issues that can arise from an inpatient documentation project. Next slide, please.

And I’ll just touch on these, because I think there’s some I think most of them are well-understood. But the operational are not to be underestimated. Once you have a critical mass of providers, especially at peak times on the unit, beginning to document device access is very important. We also learned somewhat through and this would be my vicarious learning experience to all of you: that you need to make sure that you’ve also incorporated the fact that your professional coding teams are now going to have to change their operational model, because where they used to be in a paper record and they are now in electronic record, that transition needs to occur as soon as possible. What we’re finding is that some people equate volume with quality, and so there also is a greater volume of documentation. And there are many different types of things from an operational perspective that need to be considered. Next slide, please.

Functional is also important, and I think our previous speaker also addressed this: that whether you are having as one of your drivers structure documentation, whether you’re able to ensure that you have the spell check capabilities so your notes don’t reflect the fact that most of physicians are not the best spellers there tends to be a habit to do a lot of copy, cut, and paste, which makes it difficult to really create a good picture of what is the patient story. And the other key thing is that not all physicians are typists. So having a multipronged methodology whether it’s typing, voice recognition, dictation in order to have a unified model across your health system is also a key functional consideration as you move forward. Next slide, please.

The other thing is that you need to have some a clear picture of what you anticipate from a content and quality perspective. And this issue grows as the number of providers becomes more prolific in your electronic health record. And my one recommendation would be that you, very early on, have a clear documentation standard for them. Next slide, please.

>> Lillee Gelinas:

Dr. Bascom, your 2-minute summary, please.

>> Daphne Bascom:

Great.

>> Lillee Gelinas:

Thank you.

>> Daphne Bascom:

And can you proceed to the next slide? (Pause) So one key thing that I would recommend that this Committee consider is that you have a clear content oversight group. Membership and charter objectives need to be evaluated but also that you have a documentation improvement project, even before you transition to an electronic world, because there are many things that are on paper that could be improved even prior to implementing electronic model and that you can also address some of the operational functional concerns early on. Next slide, please.

And so, again, sometimes I feel that it is like eating an elephant, tackling this problem. But the final slide does summarize what I think are some recommendations based on our experience here at the Cleveland clinic next slide, please which is, I do think that there is value from having physician documentation incorporated into the care model. And more importantly, I would use this as an opportunity to develop a more interdisciplinary, clear model. I think project structure and goals are needed at the outset. Clear organizational guidelines are a must, both from quality and a change management process. We’re very happy to share with you other unintended consequences of electronic health documentation in an acute care setting and the impact on revenue cycle, quality, safety, and communication and finally, that the operational challenges need to be identified early on, recognized, and addressed, because I think this is key to ensuring good adoption across your provider population. Thank you very much.

>> Lillee Gelinas:

That was excellent, Dr. Bascom. And it looks like that you had a number of issues that we should address, training being one the unintended consequences, that batch of discovery for us and if you could, please be thinking about that when we come to conclusions about what we might do what the recommendation look like that would be appropriate for AHIC. Thank you very much.

>> Daphne Bascom:

You’re welcome.

>> Lillee Gelinas:

We’ll turn now to Dr. Craig Joseph. Dr. Joseph, are you with us?

>> Craig Joseph:

I am here. I am here.

>> Lillee Gelinas:

Take it away.

>> Craig Joseph:

Thank you very much. It’s a pleasure to be here. I work for Epic System Corporation, and we’re, I think, the one vendor you’re going to hear from today. And so, I’m what I’m going to try and do is just give you an overview of some of the lessons that we’ve learned from customers throughout the country. Can I go on the next slide, please?

So when I sat down to think about why clinical documentation in the inpatient setting can be difficult, the most obvious thing came to me that it was I’ve been writing for my whole life since I was in third grade, maybe not handwriting well, but I’ve been doing it for a long time, and now I need to start typing or doing something other than handwriting. So it’s certainly difficult for most docs to make that transition, especially doctors who haven’t been very tech savvy in their career.

Something that we often see in an EMR is templated documentation. So we’ll give you different ways as an EMR vendor, we’ll give you different ways of doing documentation. And there’s good and bad. The good is that it brings in lots of data, so we can quickly get lots of your vital signs and your lab results and a list of your medications and bring it right into the note. But the bad side, the double-edged sword, is that that often is not there in a progress note that we would see on a piece of paper. It would be summarized by the physician. And I think, as you’ve heard, the first two speakers mentioned sometimes that it makes it much easier just to bring in data. It looks bigger. A note looks better. But in fact, it really doesn’t say anything.

An additional issue that a lot of physicians run into is trying to make a progress note thinking about a progress note differently maybe on paper than in an EMR. And paper’s really the only source of information for all the data that you want to share with someone. You’ve really got nothing other than that paper progress note. But in an electronic medical world, everyone’s got access to everything, and so it really changes the point of what a progress note should be. Can I have the next slide, please?

So is clinical documentation a big deal? It certainly is. It’s generally not as big a deal as a physician order entry. So putting orders into the system seems to be much more difficult for most clinicians to deal with. Clin doc they can get by. They’re not happy with it but they can get by. Another reason why clinical documentation is a little bit more easy than some other aspects of an EMR is that the benefits are clear. And they’ve been outlined before me, and they’re going to be outlined in some of the presentations after me. But it’s pretty obvious to everyone that when they can sit down and see a note instantly after it’s been written, even when they’re miles away or on the unit just on the other side of the hospital, it’s pretty it’s a pretty impressive ordeal coming from a piece of paper that sometimes you had to find the patient and then find the chart, and that took you 10 or 15 minutes.

One of the major hurdles in clinical documentation is time and really two aspects. First, I need time to learn the system. I need time to figure out how I’m going to make how I’m going to document quickly and succinctly, use the tools that the EMR offers so I need to work that time in, and I’m not getting paid for that as a clinician, typically and the time it takes to actually do the documentation. So is it mak is it taking me longer to write a note? Well, maybe it is taking me longer, but hopefully, I’m doing a better job, and it’s clearer for everyone. Let me move on to the next slide, please.

So who’s doing clin doc in an inpatient setting? Well, some of the lessons that we’ve learned from different hospitals across the country are, firstly, that the hospitals that say, “Well, you could write in your notes you could write your note on a piece of paper, or you could put into the chart,” often have problems, because people don’t know where to look. And so, we found that hospitals that mandate the use of the system are often more successful or more quickly successful than those who give physicians and other clinicians time to make their own choices.

Hospitals that train clinicians with real-world workflows tend to do better, too. So we like to see or we’ve seen success with training physicians instead of saying, “Press this button to do that, and press that button to do this.” In fact, what the doctor really wants to know is, “How am I going to get the vitals in? I always wrote those in my note before. How am I going to get those in quickly without having to hunt and peck and type the whole thing in?”

Additionally, training someone 2 months before go-live and then not giving them any kind of follow-up training is not going to be very helpful. Our experience is that most docs have and nurses have forgotten what they’ve learned or forgotten enough that it really is if they hadn’t learned much at all. They need to learn what they need to know, when they need to know it. Certainly there’s reasons to do training not just in time but beforehand, but they need this constant emphasis and reinforcement.

Creating template is a documentation tool. So again, most vendors have tools out there to let you do template some of your clinical documentation. And those can be often changed based on what the users are going to say. So it might work at one hospital in your if you have a 10-hospital system, one hospital might like it; and in another hospital, the physicians there might not be able to work with it. They’ve not done their documentation that way before. So you really want to get a lot of input before creating these or modifying them. Additionally, hospitals that believe optimization begins very soon after go-live have traditionally done well with clinical documentation.

So you can think about what you want it to look like. You can talk about how you’re going to want to document. But until you’re actually doing it until the patient’s there in front of you and you’ve been doing it for at least a little while in the system, you really don’t know how it’s going to impact you. And so, you might have fought, as a physician or nurse, for doing a specific workflow in the EMR, and then after you’ve gone live, you say, “Well, boy, I was wrong. It’s much easier just to do it this other way.” And so we need to hospitals need to be able to change and say, “Yep, we spent a lot of time on it, maybe, but now that we’re using it, we’re seeing it’s really not the best way, and we’re going to be willing to change and not be set in our ways.” Additionally, if the inpatient and ambulatory physicians are seeing the same type of clinical documentation tools, then they’re going to be more comfortable. So obviously, if you’ve been using a particular documentation system in the outpatient setting, and now inpatient’s going to start using that, you’re very comfortable with those tools. You know how they work. Let me move on to our next slide.

Efficient documentation and CPT specifically so templated documentation tools are good, and you can structure those. We can get data in the way we want to. Additionally, one of the benefits is that we can often use them to drive a CPT calculator. And so, many vendors offer these things. They say, “If you point and click here, if you press all these buttons there, we’ll give you what the CPT code should be in the ambulatory setting.” And in the inpatient setting, coders like those things, too. But clinicians complain and you’ve heard this already that they lose the story just a bunch of words put together, and it looks every patient looks the same. And that’s a major complaint that you get with them that you can with templated documentation. Free text works fine. If you don’t mind typing, then go for it. You certainly get the story there. But it does take a lot more time, and additionally, it can cost more money in terms of transcription. Let me move on to the next slide.

This has been mentioned before, so I’ll quickly go over it: Why do we have note in the inpatient setting? Well, we want to record clinical findings. We want to record what our plans are. We want to be able to communicate with other doctors and nurses. But also, some physicians see these things and notes as defensive tools against lawsuits. And so, they might want to fill a lot of stuff in there that they know they’re never going to look at and their colleagues are never going to look at but they think might help them if they’re going to get sued. So you have to always think about that in the back of your mind. Additionally, some people think, “I have to put this certain information in there in order to justify payment.” And can I go to my last slide?

>> Lillee Gelinas:

Just an anecdote to summarize for us, please. Thank you.

>> Craig Joseph:

Yep. And so, how can we make notes work? My major goal would be to eliminate note bloat. I don’t want we see that physicians really don’t want large notes with lots of data. What they really want are notes that tell them what they need to know. And so, we wouldn’t want to encourage physicians to re-record information that’s available elsewhere in the EMR. And we’d want physicians and nurses to document for themselves and for their colleagues, not specifically for coders. How can they do that? You can give clinicians multiple tools that they can use that work for them for their specialties. You can give them templated tools. Give them point-and-click tools if they like those. Certainly they can free-text. The drawing tools and dictation and voice recognition are two other options. And with that, I will leave it to the next speaker.

>> Lillee Gelinas:

Thank you, doctor. And that’s I think I’ve heard something similar. I’ve got my list here of common themes. I don’t know how everyone else in the Workgroup is trying to pull out of these excellent recommendations a couple of things. But losing the patient story is certainly another common theme to add.

I’d like to introduce next Dr. Christoph Lehmann, who’s Director of Clinical Information Technology at Johns Hopkins. Dr. Lehmann, we look forward to your presentation. Please begin. (Pause) Dr. Lehmann? (Pause) Did we lose Dr. Lehmann?

>> Christoph Lehmann:

I was trying to (echo) use the (echo) online system. The problem that I have had is that I have a feedback, yeah. One second; I’ll turn it off.

>> Christian Weaver:

If you could just mute your computer, please...

>> Christoph Lehmann:

Yeah, just got that.

>> Christian Weaver:

(Inaudible) computer and the audio over the phone.

>> Christoph Lehmann:

Yeah, I just did that.

>> Christian Weaver:

Great.

>> Christoph Lehmann:

All right. Thank you very much. I as you heard, I work at John Hopkins University. I’m one of the Co-chairs for the Clinical Documentation Committee. Just a little bit of historical background: We currently have our home-grown electronic patient record, which we are planning to retire, and the functionality that we have in our electronic patient record will be taken over in part by the Eclipse’s SCM product, which will be used for daily documentation; and in part by the Microsoft product Amalga, which will serve as a data repository. Next slide.

The this giving this talk actually made me sit down and essentially get rid of all the slides that I had and started from scratch about what documentation why doc why we use documentation and what are the guiding principles for our documentation implementation that we think works. So, you know, why documentation you heard that before: It makes information available across the providers. And I’ll ask you to reflect on clinical decisions making, which is not trivial. It serves as a legal document. But mainly and the biggest chunk of our documentation let’s be honest about this is to support billing. And it’s driven by the ‘95 and ‘97 documentation guidelines from CMS, which totally changed the way providers have to document. I made, in the last week, phone calls to colleagues all over Europe, in Chile, in Canada, and tried to get in a feel of the amount of documentation that’s being done in these other countries. And to make a long story short, they’re just shaking their heads when they hear about our review system. Next. (Pause) Oh, the hidden slides are there. Can you go next?

There are a number of factors the literature is actually relatively sparse on this there are a number of factors that influence the satisfaction of our providers: efficiency, of course; availability; that the information is up to date and current; that it’s brief, concise, and succinct; that it’s organized in structure and providers can find what they’re looking for; and that the quality is good. Next.

And when you look at the impact it can have, you heard that the documentation’s available but changes work processes. There are good data out there. If do you bedside point-of-care systems, it increases documentation burden by 17 percent. If you move it away from the seven the bedside, it might go up as high as 50 percent. It changes the way structures documents are done. It changes the structure and content and may introduce new mistakes makes provider concerned. It might decrease their confidence in what they see. Next.

So I will be talking to you about oh, one more thing: The other thing we’re up against is this incredible proliferation of forms. And I don’t have to tell you in detail that every new process introduces a new form, and every physician thinks he needs his own specialized form of that. Next slide.

So what are the guiding principles that we agreed upon when we decided to embark on clinical documentation? First of all, we are doing data element reusability, and this is something that is completely novel for us as a concept. And I will go in detail in a little bit, but the idea is that we are a care team, and as a care team, we must be able to use every member of the team in the part of the documentation and in the design of different documents. And I’ll go into the details on that in a little bit. We have to come up with new naming conventions, because in order to make data elements reusable, we have to be able to access them and make them available in different documents and then different locations.

Another really critical decision was that we completely change the process of how we develop any kind of implementation within our Eclipse’s SCM system. The thing the goal is to fail often but fail early in the process. And again, I’ll tell talk about details. And then, of course, the documentations can we have the next slide?

So the first thing that you heard me say is the data element reusability. I apologize: This slide is busy. But if you lean in, you’ll see this is a slide about a subset of provider documentation documents. So you can see up in the right upper corner, there’s the summary. On the left, you see the history and physical. You see a consultation note on the lower right. And one thing that you will realize: If you can squint your eyes, you will see that the medications, for example, appear in most of these documents. Other elements, like allergies, that may have already been in the SCM system appear in most of these documents.

So one of the goals that we have is that items such as vital signs can be pulled over from documentation that nursing has already completed in the nursing assessment that elements like allergies can be pulled in from previous admissions and modified and used in this document that elements like the past medical history that was done in an H&P can also be used in the consultation note in a modified version.

So we decided, “We are one care team. It’s important for us to have our data in a very granular fashion and allow providers to take data elements from previously crafted documents and pull them into the current document and modify them to reflect the cr their reality and use them as part of the documentation.” That is that is, for us, a very big change, thinking that we didn’t structure our history and physical notes till about 10 years ago, when we introduced our electronic patient record, the first structured note. Next one. Next slide.

You heard me talk about “Fail often but early.” And I apologize. I was just trying to get too much on these slides for this format of displaying them. But may I’ll talk you through it. Do you see these four swim lanes there? There’s the condition workgroup. That’s the analyst builder, the design team, and then the references. The process starts in the upper left corner. The clinician says, “I need this document.” And he talks to an analyst builder, and the analyst builder will mock it up you know, there are visual tools that we’re planning to use: video, mind map and mocks up what he thinks he hears the provider say. And you we you all know, pru that analysts never understand what clinicians say the first go-around. So it goes back to the clinician. The clinician says, “No, that is absolutely useless.” And there are multiple iterations of this until both of them agree that they have something that they can pass on. We have a very small design team. Once this mockup is done and both parties have agreed upon the design team looks at it, and if there are problems, it goes back to the previous process. And if it’s if they if the design team agrees, it goes back to the builder to be actually built. At this point, the amount of effort that has been spent is minimal in form of actual programming. But not until then do we go and let the analyst build it within the system and actually spend time and energy on this. Next slide.

Naming conventions are critical for us. We believe that we well, first of all, we are sick and tired of clinical documentation systems where the same information let’s say a patient’s heart rate is stored in different tables and different fields just because a different unit go went live and had some specific attribute that they wanted to attach to an observation. So we have spent many, many weeks our nursing documentation group to look at flow sheets, break down the observations into smallest parts, look at the attributes and we’ve come up with a nomenclature and a design structure for the underlying data to make it very granular and put them together, then, into different ways of combining these granular data into merged sets or bordered sets. This allows us to use to always store heart rate in the field it’s called “heart rate” no matter where it’s coming from, whether it’s done by palpation or it comes from EKG monitor or any other mode, and allows us then to find this data and generate reports downstream that truly make sense. Next slide.

>> Lillee Gelinas:

And Dr. Lehmann, you’re at your 2 minutes. And if you could help with us some conclusions around what you’ve learned, which is again, the purpose of this segment is for us to learn from you all and see what type of recommendations we might want to make to AHIC.

>> Christoph Lehmann:

Yeah. So the one let me just abandon this here. So what we have learned is that we are entering a completely new environment. Clinical documentation, as you as we have had it in our electronic patient record, is difficult to use. Data is difficult to access. And providers spend a lot of time being typists. We have learned that we need to go to the model of a care team where everybody participates in the documentation process and the final document is a collaborative effort of the team. And that includes nurses, physicians, respiratory therapists, social workers everybody who has a hand in this generates this new documentation.

Secondly, we have learned that data utilization is critical that data should be pulled forward and modified and used again. And in order to do this, we have to have a granular data structure.

And thirdly, what we have learned is that you have to conceptualize any kind of clinical document up front before you spend a lot of time and energy actually building them in the system and having to renew to destroy it or modify it and spend a lot of time and effort. We have learned that the hard way. And we believe that this model of mocking it up and obtaining general approval before it’s implemented is the appropriate way to go.

>> Lillee Gelinas:

Okay. The data element reusability, I’ve added to my list here of (inaudible) beginning a common theme. Thank you very much.

>> Christoph Lehmann:

My pleasure.

>> Lillee Gelinas:

We’re going to move now to the experience of the Gundersen Lutheran Health System, with their implementation of the electronic health record. And presenting today is Deb Rislow, who is the Chief Information Officer. So

>> Deb Rislow:

Hi.

>> Lillee Gelinas:

Please, welcome to the panel, and we look forward to hearing from you.

>> Deb Rislow:

Thank you very much. I appreciate that.

Let’s move to the next slide for the demographics about our organization. The main takeaway here is that we’re an integrated health system. We have about 41 clinics that are automated. We have been, for 8 years, in a pure electronic health record system, and we’re partially automated in our ambulatory setting. And what I’ll be presenting today is our learnings from both of those situations as we complete our full implementation of our acute care setting with the Epic System on November 1 of this year. Next slide, please.

This shows a little bit of the information in regards to our spending. At this point, we’re utilizing about 5 percent of our net revenue for technology. And I just thought that was an interesting point to be made. Next slide, please.

The mission and I think most importantly here is that, as an organization, we develop an EHR implementation so for each system that we’ve put in and actually implemented fully, we’ve developed that mission. And it’s patient centric. And that’s one of the most important things: that for all care providers to buy into a technology and to do the right thing for the quality patient care. The mission must be centered around providing the best patient care that you can through the technology. Next slide, please.

So the issue that you’re asking us today is, “What can we do to actually adopt inpatient electronic medical records more efficiently and still meet all of the requirements that we have?” And I think that we have quite a bit of learning and, very similar to some of the things we’ve already heard, a couple of new issues that I hope I can share today. Next slide.

First of all, we sit down, and we figure out what our desired income outcomes will be, making them as metrically defined as possible. It’s important that we identify measurable outcomes so that we can track the baseline of where we’re at today and then, after implementation, track posts the improvement of patient safety, very critical for us; the chart availability; nurses’ time at the bedside, which we do have baseline measurement on and have goals in which we hope to improve that with our Epic slides; improving the accuracy in charging; the data availability and the transparency of that data; and then also the ability to exchange health care data with other organizations that are also utilizing systems that are CCHIT certified. Next slide, please.

So how big of a problem is it, and why is it a problem to adopt electronic health records? And I think the main thing that we’ve learned through our experience is, “Never underestimate the magnitude of forces that reinforce complacency.” So in other words, change is very hard, and you have to continually bring that message back to the end user group and to the entire organization and talk about it openly that this will be a large change and help the staff to implement the change and offer them support through it. Next slide, please.

So, best practices for implementation is for the entire organization to create a shared need why are we doing this? and then a shape vision so that it’s clear to everyone across the organization so that no one’s left behind in understanding what the objectives are to implementing an EHR. Then we mobilize that commitment, and that means dedicating resources. It can’t be a project that you put on top of another project and another project. The commitment has to be there across the entire organization. Once the system is implemented, the change has to last. And I want to talk a little bit here about how we can make that happen and then, of course, back to monitoring progress, studying those metrics early and continuing to monitor those to see if we’ve met those objectives that we set out to do. Next slide, please.

The best practices that we think will help others is really a commitment that no one gets left behind. All the way from the system selection process through implementation and training, everybody needs to be involved. All methods of communication have to be utilized. Training has to be offered at, you know, a rapid pace and but a thorough pace. It has to be very strong physician leadership. There’s no way that you can implement a full EHR without that. And I’ve heard several other speakers mention that. The integrated care practice model at the time was, all services across the organization are involved in the electronic health record. This is not just a nursing or physician documentation system. It’s all patient care providers that are involved and then a solid infrastructure and a high number of available computers. You heard earlier that nurses tend to migrate outside the rooms and to the walls or at a central location, and that’s very true. You also need to have workstations available in the rooms and available also in central locations. You cannot have enough computers in order to make your go-live successful. Next slide.

Again, more best practices: To really set the stage that there’s no option to opt out, if you’re going to implement an EHR, you cannot have a percentage of physicians or nurses that have the authority or opportunity to opt out of not utilizing it. And that’s a very strong message, and you have to be clear with your senior leadership on how you will manage particular situations where folks may become despondent and not willing. Reasonably realistic discussions about impact of the exchange: I mentioned that earlier, and I cannot stress that enough that it’s okay to talk about that and to share that this is a big change and to help the staff do that, because resources must be dedicated. This is not a secondhand project. I’ll say that again. It has to be the top priority of the organization at the time that you’re going live. And while there’s other projects that will be under way, this one has to take top leadership. The leadership: Someone else mentioned, as far as administration, being huge in terms of recognizing that this project is out there. I can’t speak to that enough. And finally, the Big Bang live: We’re strong proponents after learning through several methodologies that if you’re going to a live system, you need to go live with it and do that all pretty much in 1 day. If you try to piecemeal your live, you’ll find oftentimes that you’re optimizing while you’re still implementing. And it’s better to go through the pain all at once and then begin the optimization immediately after live. Next slide, please.

Normal part of the change I can’t say this enough is that people really do tend to experience change differently, and we can’t underscore that enough. As many will be excited, a lot are concerned, worried even about their own job security. These are all normal conditions of the implementation, but I think what we don’t do is talk about it enough and offer support. And advice to folks that are going through that change. Next slide, please.

>> Lillee Gelinas:

Deb and you’re at your 2 minutes. Thank you.

>> Deb Rislow:

Yep, thank you. Next slide, please.

We just use this slide when we’re speaking with folks just to show some of the phases that you go through with implementation, some has a little bit of humor to it, but it’s also real, in that you start out with shock and eventually you get to the moving on stage. And you will find that organizations that have gone live. About 3 or 4 months after they’re live, they really can’t do without it. Next slide, please.

Engaging physicians in the process is absolutely paramount. They are the largest group that will struggle with the change that we’ve seen, by far. I think Epic noted that and has expressed that to be true. That also trickles down, then, into other areas of the patient care providers. Next slide.

So solutions: What have we done to engage the physicians? I think we’ll be the first hospital that will go live through partial dictation, so we’ll allow the information to be compiled from previous information that’s been entered by other folks and then allow the physician to dictate and then extrapolate more information. They can also enter typed text if they wish. This will be new, and we’ll be happy to share how that goes at another time. Next slide.

So solution: The process has to be efficient and clinically robust, individualized, solution-based training. The training I can’t stress enough. I think we’ve said that a few times here just-in-time training. So we should be sure to train as close to live as possible, and that means that the schedules will have been to be very well coordinated. Playground environments need to be available so that after training, folks can go back and use the system and actually use live data, so make sure your interfaces are in place before live so that they can see things that are real and have meaning to them. Next slide.

Create views of the physician and associate staff super users. So make sure you have stuff that are actually on the floor at the time of live that our physicians and the interdisciplinary team members and the nurses make sure that folks that are very familiar with the workflow are there on the floor and assisting others that are maybe struggling with actually utilizing the system at the time of the live. Next slide, please.

Take your strongest physicians, including some of those into super user groups. Make sure that the nursing and ancillary staff have the best environment to learn in, so take some time on your training rooms. Pick physicians that are at most risk, meaning those that are maybe struggling or will struggle, to be on service on the second week, not the first week. And then indeed, again, just to mention to intensify the MD, the PA, the MP super users at the time of the live so that physicians see that support that’s around them. Next slide, please.

Post-live, the dedicated physician super user time must be clearly supported by upper management, so physicians that are working in clinic or the hospitals that they have approval to be dedicated to the implementation and not dinged for maybe not seeing patients during that time but are actually reimbursed for their efforts that go into the live. Next slide, please.

That’s all I have, and we’ll talk about questions later. Thank you.

>> Lillee Gelinas:

Okay, thank you very much. And we appreciate the note that the cost of technology was 5 percent of your net revenue I think that was the first cost that I’ve heard because this Workgroup has had testimony in the past noting that the #1 barrier to the adoption is cost. And we’ve had one, two, three, four, five presentations now, and the barrier to adoption around cost, at least if that has been one, has not come through. So when we get to the discussion portion, the notion of the cost of the technology as well as the resources, as Deb said, that must be dedicated, I’d like for our panel just to be thinking about that, because I’ll come back to you, because if that’s a myth, then that’s a contribution that this Workgroup can make.

We’ll move now to Dr. James Walker, who is the Chief Health Information Officer for Geisinger Health System. We’ve had testimony from Geisinger in the past, and they’ve been extremely helpful to us, helping to define what we’re trying to do. So Dr. Walker, welcome to the Workgroup. We look forward to hearing from you.

>> James Walker:

Thank you. It’s a pleasure to be with you today. If we could go through the first five slides, sort of 5 seconds apiece, they just illustrate that we’ve been doing this a while or doing it inpatient/outpatient across 40 counties, with a lot of outreach EHR, with a patient health record with 107,000 patients in it. And most relevant, we went live in our largest hospital October of 2007 with documentation and order entry.

So on Slide 6, then one more slide, please. So the questions that I think you wanted answered were, “How big is the problem?”, “What are some success stories?”, “What are some best practices that we think we’ve found?”, and, “What needs to be done in the future to increase documentation, efficiency, and quality?” And so I’ll address them in that order.

The next three slides are another sort of quick trio, if you could just show them quickly. The first one it’s a big problem. The recent study published showed that there’s still very little diffusion of this. The next slide shows that even for those that are diffused now, this is a study in outpatient clinics, but it’s, I think, consistent with the experience of us those of us who do it that even where you have EHRs, they’re not being used very fully. And then the next slide is my reflection on what’s going on: The problem is really bigger than the statistics suggest if what we’re saying is, “To what extent is electronic documentation being used to drive improved processes and improve patient outcomes?”

So the next slide, then, addresses, “Why is this the case?” I think, the more we do this, that the largest reason for the failure of adoption, and particularly effective adoption, is the fact that HIT has not typically or consistently been conceived in terms of process transformation. People have talked some about teamwork that this is about nurses and respiratory therapists and physicians and lots of other people working together pharmacists and desk clerks to provide high-quality care. And the documentation needs to support that kind of teamwork. And if you don’t start by saying, “We’re going to transform the way we do things; how can the EHR help us do that?”, then what you’re prone to end up with is a very expensive and not particularly useful tool that it’s understandably hard to get doctors and others to use.

Second reason why and this, I think, is more important barrier or another way of saying, “We have a lack of resources.” The lack of process redesign skills and funds to pay for it means that most implementations are done in a way that would be predicted by an informatician to be hard to use, unlikely to engender widespread use, and unlikely to improve processes and patient outcomes.

The third thing is that HIT is still just hard to use. The software, even in the very best instances, remains difficult to learn, difficult to remember, and hard for people whose most of whose cognitive effort needs to be directed be to something besides the computer.

The fourth thing is, any time you change processes, any time you introduce something as big as HIT into a system, it’s going to rearrange work. It throws a spotlight on quality and safety in ways that were not possible before, and it means that people have to document things they never had to document before. It means that different workgroups may end up with work that they didn’t use to have to do, because in terms of the system or just the software, that’s the way it needs to be.

The next reason I think adoption has been oh, I’m sorry. I’m still on that slide. The next reason is because we’ve conceived HIT, going back to that process transformation, in terms of tasks. Order entry, documentation, scheduling whatever it is, we’ve been prone to design HIT to mirror the old world of one person doing one task rather than a process enabled by a carried out by a team. And then costs are obviously important. We spend 4.2 percent of operating budget on IT, all things in. We would not consider that we were serious about it as a strategy if we weren’t spending at least 4 percent. Then the next slide, please.

So some success stories next slide. This is outpatient and inpatient, but it’s very illustrative. Our organization decided 3 or 4 years ago that we were going to provide better service to referring physicians and made an agreement across the organization that we would get consult notes to referring physicians within 24 hours, period. Once we made that commitment, the only way to carry it out was using the EHR. We created a functionality in the EHR that enabled it. And with just that agreement, no other enforcement, we’re to the point we were to the point within 6 months, and still are, where 80 percent of outpatient notes are created electronically and transmitted within 24 hours. Next slide.

A similar story on the inpatient side has to do with auth notes. There’s a very good business case for getting your operative procedures documented and reported out so that you can get it to the revenue cycle people. And because of that, we did a special project created 262 custom templates so that each physician had his or her own template for Lap Coley that was customized to the way they did it. It required the insertion only of three or four data elements in any normal procedure. We got 262 of those built in 6 weeks. I could tell you the process. We were very careful to make sure that it met all kinds of quality criteria. And within about 6 months and since, we’ve had about 70 percent of auth notes created electronically, again with no enforcement except the Chief of Surgery being a strong supporter of the program. He has not dictated an auth note in 5 years of this now. Next slide, please.

So we went live in October with the large hospital. And as other people have said, what we said at that point was and it was really an agreement among the clinicians and clinician leaders in the organization “There’s no sense writing a note if it’s going to be dictated and on the chart 48 hours from now.” And so, we have an agreement across the organization that all inpatient notes are created electronically. We try to create a very sophisticated, I think, way of creating templates that are very usable and capture the right things and are simple and short. And we have about 100 percent of notes entered electronically if you could go on to the next slide. And just parenthetically, within 6 months of go-live, completely confounding my expectations, we also have 70 percent of orders ordered with order sets, which, as far as I know, is about 50 percent higher than anything anyone else has reported.

Okay, so success stories fundamentally, this is about being an integrated care system, being large enough to be able to afford this, having the right kind of incentives to care about whether nurses can work efficiently and physicians and respiratory therapists and everybody else on the team and so forth. Next slide.

And best practices that we think we’ve identified next slide, please. Number 1 is not on your slide, but I’ll start there is, to start the design of tools from the report from the quality report, the safety report, the efficiency report, the reimbursement standpoint make sure that the note templates that you create really are going to capture the information that you’re going to need to report to yourself and others how you’re doing. One thing that does is, it means that users look at those templates and realize that it really is in their interest to use that template, because there’s no possibility of remembering all of the right things and saying them in all the right ways to meet the genuine blizzard of regulatory and payment and other requirements.

I already talked about commitment to transformation. If you don’t have that, this is going to be too much trouble; too much money; and you’re going to quit somewhere along the way, maybe after you’ve declared a successful implementation. You got to make it fit everybody’s needs talked about that already. Careful design of templates I can talk about again, but they’ve they’re vetted by pharmacy, by medical records, by the quality team, by the innovation team, by obviously the clinical teams. Make sure that they really are usable in all those different dimensions. We focus on the assessment and plan. We try to keep the notes simple. We’re confident that we can say, “Look, all of the rest of that data is in the EHR. We can document the physician or whoever’s writing the note the nurse or the respiratory therapist looked at it. And so, what we’re focusing on in notes is the things that you can’t get by looking at the labs and radiology and all of the other data.” Next slide, please.

>> Lillee Gelinas:

And doctor, you’re at your summation time here. If you can conclude for us and help with us our

>> James Walker:

Okay. If I could have the next slide, just some these are some things that I think we need to be addressing as we go forward: evidence-based templates and obviously, there’s a policy there’s a national agenda here to say, “Who” you know, “What is the evidence base for low back pain or for acute MI or for whatever it is,” and create standards so that then we can build templates that lead to linked notes and order sets make things much more efficient. And maybe I can let you just look at those.

I think just responding to what some of the other people have said: We require training. We’re convinced that it won’t be very long until an organization is sued successfully because they can’t document that they trained EHR users and documented that those users are capable of using it safely. And at any rate, we think it’s important enough that we document competency-based training for every user before they’re allowed in the system before they’re allowed to take care of patients. And then some other things: careful organization notes we went to a lot of work and that’s back to the team to make sure that all the notes the progress notes, the OR notes, the nursing notes are all structured in a way and stored in a way and displayed in a way that people can find them and use them easily.

We agree with the idea of whole-hospital documentation go-live. We couldn’t figure out a way safely to have some people documenting electronically and some on paper. But we do not think Big Bang is very smart. We are very careful to phase things like results review and electronic communications and order entry and documentation radiology image availability so that people only have small things to learn. It’s just that the whole organization learns them all at once.

You got to have a rapid response team. When we went live on inpatient this wasn’t all documentation, obviously we resolved 5,000 issues the first 2 weeks we were live. We had a 24-hour command center that went through those and resolved them.

And I think that’s probably enough, and we can save the rest for the discussion.

>> Lillee Gelinas:

Thank you. It struck me you know, I could you could be here on the phone. We’re here in our conference room, and as we’re hearing these excellent presentations, there’s another thing that I’m adding to the list here: the incredible amount of tremendous work, the amount of duplication that must be occurring each organization is creating their own templates, their own physicians templates, their own nursing assessment pieces and we think of the cost across the U.S. health care system. I can’t even begin to fathom what that must be.

>> James Walker:

That’s right.

>> Lillee Gelinas:

So did I hear that correctly?

>> James Walker:

Yes, that’s exactly right. It’s a major, great tragedy.

>> Lillee Gelinas:

Well, thank you for that contribution as well as others. And I did pick it up correctly? Your cost was 4...

>> James Walker:

...4.2 percent of operating.

>> Lillee Gelinas:

Operating. All right, not gross. Okay, thank you.

Last but not least is, then, so patient are our friends from Midland Memorial Hospital in Midland, TX. Midland staff also presented to the EHR Workgroup on their successful implementation and adoption of the VA vista system. For those of that you are looking on the Web, they would like to go back and see Midland’s presentation to AHIC’s Electronic Health Record Workgroup, it occurred July 20, 2007, if you want the specifics around that implementation. But today, presenting for us are the Director of Information Systems and the Vice President of Patient Care Services, who have been real friends to the AHIC EHR, as we’ve really tried to understand implementation issues. So I’m not sure who’s going to be speaking first, but I’ll turn it over to our friends at Midland. (Pause) David or Margaret, are you with us? (Pause) Hello?

>> David Whiles:

Thank you.

>> Margaret Robinson:

Can you hear us?

>> Lillee Gelinas:

Yes, we can hear you. Who’ll be going first?

>> David Whiles:

All right. This is David. And just real quickly, Margaret and I will be playing kind of a tag team here. So I’ll start off and then hand it over to her, and then we’ll go back and forth.

>> Lillee Gelinas:

Great.

>> David Whiles:

Next slide, please. Just real quickly, this kind of gives you an overview of the environment that we operate in. We are a community-based physician or community-based hospital. Our physicians are independent contractors. We paved most of the obstacles. By the way, I wanted to say “Thank you” to the rest of the presenters and actually “Ditto” to almost everything you said. Next slide, please.

Just an overview of our implementation timeline not getting that slide up there we go. Milestone dates: Our first application go-live was in October of ’05, and we removed all vestiges of the legacy paper record in February of 2007, which was basically our ultimate and final incentive to the physicians for using the system. Couple of notes here: You did mention, we did adopt the VistA system from the Veterans Administration. One note: You mentioned earlier that you had not seen cost barriers listed, which we don’t have in this presentation, but I can assure you, for us and for many others that I hear of, that was a major hurdle for us to overcome, as far as the entry-level costs of getting into the EHR. Next slide, please.

>> Margaret Robinson:

With that, this is Margaret, and I’m going to take over on lessons learned. Clearly, we started with physician buy-in. I think every speaker has brought that up, and it’s just very difficult to look at implementing a system without physician buy-in. Key to us was early engagement in the process. We had a physician committee that was established. The other thing being that we’re primarily independent physicians, having remote access was a key to their success. Any physician can get access to the electronic medical record in their home or office, and that certainly has been a plus to their adoption of the system. There is that ongoing resistance to change, and the enthusiastic physician leader is a must. There has been some discussion about one on one attention. Particularly, one of the speakers spoke of the working in the real-world workflow. And I think one of our critical successes with physicians is having analysts available to work with them, not only on the primary go-live, but as they begin to better understand how to use the technology, being able to follow back up with them on one on one and look at how to apply this to challenges they’re facing this week.

We do have standard templates. We have opted to allow them to be customized by each physician. That really has to do with how they perceive the workflow. We want we did not want to mandate a standardized template for all general surgeons or all cardiovascular surgeons, because we didn’t want that to be perceived as a barrier to the electronic medical record. There are clearly advantages to having an absolute standardized template when one looks at how to pull the data out from a quality and other reporting elements. So it’s a tradeoff we deal with.

Hardware has been brought up, and that certainly has been a challenge. Also bigger nurses’ stations those computers take up more space. And when you have mobile computers, you also have to have docking locations so batteries can recharge.

If you go on to the next slide, it just emphasizes here that conversion is challenging to any staff, whether it be physicians or clinical staff the natural resistance to change. Some of the older staff may not be as computer friendly, but actually I’d modify this a bit and say that age wasn’t near as much a function as to how much they used computers in their own personal life. And we actually did a study on the nursing staff, and almost everyone would say that they knew how to work a computer, but that, to them, was being able to get on the Internet and look something up. The key to whether they could make the transition to electronic medical record was if they used if they knew how to use a software program. And it really didn’t matter which software program, but if they were successful in Word or in Excel or in PowerPoint, then they generally knew how to navigate computers to be successful in the transition in electronic record.

There it certainly creates a difference in work routine. And we also deployed a rapid-cycle problem-solving group, most successfully during our bar code medication administration, since that was such a critical patient safety issue. And every morning, we reviewed the problems from the day before and as the multidisciplinary team looked at what those solutions should be. There are other examples on the sheet.

The hardware of the environment, that being paper and computer, certainly exacerbates the issue and creates frustration. We’ve probably as David went through our timeline, we extended that a bit. That pr that was as much related to the available human resources we had at the time and part of our cost issues. So we did try to expedite things, but we were we realized very soon we needed to try to eliminate paper and have the official medical record be the electronic medical record. This is probably more anecdotal, but the initial tendency is to blame the system for everything. So anything that didn’t work, it must be because we’re now on a computer system.

With that, I’m going to let David talk about the physician adoption, because HIS was intimately involved in that process.

>> David Whiles:

Can we go to the next slide, please? I think others have pointed out that it’s extremely important to engage the physician not only early but continuously throughout the process. We had early engagement, well before we signed any contracts for implementation of the EHR with the physicians. We had typically a vendor demonstration or demo and would they would come in for an afternoon and kind of give a dog and pony show. We scheduled a full week long of showing the system to as much of the staff as we could. We had a couple of nights dedicated specifically for physicians, so we began engaging the physicians at that time. We had a physician advisory committee through our early due diligence process and engaged as many as we could. We had a formal physician advisory committee that was formed during that period. And we included the chief of staff in virtually everything we looked at, in terms of deciding on which EHR to implement as well as just the fact that we wanted to implement one. After that decision was made, we continued engaging the physicians through what we called the Edith Physician Advisory Committee, “Edith” being the name that we adopted for the system ourselves. We identified early adopters with the physician community and really leveraged their success in using the system to kind of spread the word to their peers and the other physicians on staff.

We did one earlier presented said presenter mentioned they used a lot of reports, and we used a lot of reports during this period as well, to identify the utilization of the system by physician for documentation, for order entry, for other purposes and identified low u what we called low utilizers and focused in our attention on those. We found initially, we started largely with one-on-one custom training with all the physician staff, because we didn’t feel that or we kind of had heard that many of them would not attend a classroom. We then opened up classroom settings in our training rooms for physicians and were pleasantly surprised that many physicians actually did come to a classroom setting. So that certainly helped in the training process to get a group of physicians rather than having to spend that much time one on one.

Certainly the electronic signature their being able to complete their records electronically rather than having to go to medical records was a plus for them. And Margaret mentioned remote access as being a very key success factor for us.

As far as individualized structured documentation, we also have spent a great deal of time sitting with individual physicians, customizing templates our templates to that physician and to his practice. We didn’t see a lot of buy-in when we just kind of brought up or floated a b the trial balloon of standardized documentation. So, you know, I think that was key to getting the physicians into the system. Most of our structured documentation there was other terminology used earlier, but we have many reusable data elements we call them data objects that are that we’re able to link to our progress notes. For example, so when a physician opens a progress note, it immediately fills in for again, kind of customized to what he wants. It can automatically pull in most recent laboratory results, vital signs, their current active medications, active problems so a fair amount of the note is populated for him prior to his even starting to work on it.

>> Lillee Gelinas:

David, y’all are at your 2-minute mark, and I know that there’s a tremendous amount of anecdotal and perceived improvements.

>> David Whiles:

Okay. Let me just quickly go through again, one of the keys to our success, I think, was just to continuously engage the physicians. I call it stalking. There are have been occasions that we’ve actually had to chase physicians down the hall, but we’ve been very persistent at it and been pretty successful at it. Next slide, please.

This is just a chart that kind of gives you we tracked weekly the physician utilization system and how the adoption went. Next slide, please.

One of the biggest, biggest issues I think we find is that physicians, in many cases, just simply don’t have the time, and it’s very difficult to get them to sit down with us to go through their individualized documentation templates and their individualized order sets. Those that have been willing to do that have been very successful in using the system. And other physicians hear of that and ultimately do take the time or find the time to carve out of their day. We engaged or used some early incentives for physicians to utilize the system, including a professional service agreement that we pay them up to $1,000 for their time that they spend on training and learning and using the system. Next slide, please.

Again, just very quickly, kind of a chart on our physician order entry rate from early adoption up through this was probably sometime in May of this year. Next slide, please.

At this point, I’m going to go ahead and hand it over to Margaret for kind of the anecdotal improvement that we’ve noted, as well as wrapping up.

>> Lillee Gelinas:

Margaret, what would you like to do, since we’re out of time? What I’m excited about is, when you presented over a year ago now, you were still just putting some anecdotes together, and now it looks like you have real data. We want to spend time in some robust discussion here. So how would you summarize you’ve got about I think it’s about 10 slides here how would you summarize what the accomplishments have been and therefore what you’ve learned?

>> Margaret Robinson:

Thank you. And we realize there are a number of slides on the anecdotal and perceived improvements. But we recently had the opportunity to have Perot Systems, which is the national and international consulting company, come back through and do an independent analysis of our electronic health record implementation. And what most of that is is well, actually, what the content is is a partial summary of their report. So I think what’s most significant out of that is that that was an independent review and audit of our facility. They spent about a month looking at our data and our staff, and we wanted the committee to have that information primarily.

The summaries fall in four broad categories, and that includes clinical adoption, safety and quality, operational improvement, and return on investment. I would just emphasize, in summary, also from what I’ve heard from other folks, that I think remote access was significant for us on the clinical adoption. Under safety and quality, being able to have methodologies to gather information for core measures, for other safety initiatives, certainly is enhanced having an electronic medical record.

Looking at systems’ operational efficiencies, I think one of the most surp not surprising, but just the fact that the chart is available to everyone simultaneously is very liberating that a variety of depart of clinicians can chart simultaneously. Case management can now do concurrent review easily quality management as well.

And then certainly, on the return on investment, we would not have been able to implement an electronic medical record if we had not chosen the VistA option, because it just would have exceeded our financial capability. And as David alluded to, we get many visits from other facilities that are seeing that as a challenge. So I certainly would want that to remain on your list of concerns. Thank you very much.

>> Lillee Gelinas:

Margaret and David, really, congratulations. And the Perot System’s independent analysis of your implementation must really be heartwarming to your organization that spent a lot of time.

Let’s move to discussing what we’ve heard. I really want to thank Bonnie Anton, Dr. Bascom, Dr. Joseph, Dr. Lehmann, Deb Rislow, Dr. Walker, David Whiles, and Margaret Robinson, because they’ve certainly given us quite a bit of food for thought. And I’ve been trying to compile a list here. And I raised that ugly elephant in the room when we had talked about adoption in the past: The #1 barrier that we’ve heard from physician practices as well as the hospital sector has been cost. And through all of these presentations, I’m not so sure I heard “cost.”

And then the second piece is, what would a recommendation look like coming from this Workgroup? Now, David and Margaret, in your testimony a year ago, you did give us some sense of cost that was significantly less than the implementation of a private-sector system, because you actually took Vist A and adapted it to your circumstance, correct? So do you have a dollar amount or the ongoing just like let me go back here. Geisinger spent 4.2 percent of operating budget; Gundersen Lutheran, 5 percent of their outpatient revenue. We didn’t hear anything about cost of adoption implementation, so...

>> David Whiles:

Yeah, I don’t have a number of our ongoing costs, as far as the percentage of IT to net either net revenue or any other metric that I can share. Our original budget was for the EHR component was about $6 million. We had some more budgeted in there, but that was not for EHR. We came very close to meeting that, which was about a third of what we found would be comparable in the commercial industry. So it was quite significant for us, as far as that entry-level cost. And that cost of entry is really more prohibitive than ongoing costs, I think we find.

>> Karen Bell:

Lillee, this is Karen Bell.

>> Lillee Gelinas:

Hi.

>> Karen Bell:

I’m also wondering if, in part of cost, we look at overall resources, because the concern that obviously, staffing in hospitals is a problem right now. So were there physicians or nurses, for instance, that literally had to give up their clinical work to become full time to run the implementation team? Did some of the panelists bring in outside help to review the workflows, documentation, all of that, or go to consultants? So and I guess, then, there’s one other question about the cost: How much of it was software, and how much of it was hardware? So I’m just sort of get wondering if a couple of the speakers might be able to give us a little bit more of a sense of how they actually dealt with resources in the bigger picture.

>> James Walker:

This is Jim Walker. We figured direct costs project costs, analysis, implementation teams and when we looked at direct costs, software costs were 20 percent of that and we used a software product that is known as one of the most expensive so that the software costs are actually a fairly small part of direct costs and of course, our indirect costs: retraining all of our administrative people to be able to do needs assessment, to be able to support projects, to be able to do process redesign, to be able to specify what they need in the next version of the EHR to support their work better. The enormous hidden costs throughout the organization, we think, are probably bigger than the direct costs, although we don’t have a good way to measure them. So I think costs clearly are a big issue.

One of the reasons integrated systems do this more than other groups is because they can spread those costs. They can do it once, as you know, as the Chair said, you can do this once and use it in 42 community practice clinics, instead of having to do it every time for every different group. The costs are huge. I think software costs are overestimated. I think one of the things that we’ve seen is that some of the biggest-name organizations in the country have neurosurgeons using the same tools that family practitioners use. And that is partly because you go to your CXO office and say, “Okay, this is going to cost us $20 million or $5 million or $120 million, or whatever it is,” and if you said to them. “And by the way, we’re going to charge we’re going to have to put another 15 percent of that in for doing the process analysis before we even configure the EHR to make it useful, and then we’re going to have dedicated teams after go-live to go back in and look at once people actually understand what the tool can and can’t do, look at processes, look at people’s use, do retraining, do process redesign, and do EHR redesign,” those costs are so large that most organizations, including ours, just punt.

And so, I think cost is a genuinely serious issue. And I think, for the most part, we haven’t even really talked about it in its full dimensions. Usually, what we’re talking about is just buying the EHR and kind of putting it in.

>> Bonnie Anton:

This is Bonnie. I agree. I don’t have the cost for our implementation, but the point that was made about after you go live, the costs that are involved can be quite phenomenal. And when you think of staffing, as was mentioned, how it’s difficult to staff on the units, then you have to pull these people off to come to a classroom. And from the other end of that, you’ve got an instructor sitting in the classroom expecting 20, 25 people to and only 5 people show up. So that cost there for instance, in our situation, we build our order sets internally. All physicians, for instance, in orthopedics have agreed on an order set. We would not spend the money to have Physician A have his order set, Physician B have his order set.

So I think the point that was just brought up about the cost of after you go to implementing for instance, we have a rounder, you know, who’s an analyst, but they also round. So there’s a lot of those costs that you have to consider after you go live also.

>>Lillee Gelinas:

So I wonder if there is and Jon and Karen, I’ll need your help here, but I just wonder if there is a recommendation for transition to AHIC 2.0, because I do know this Group has already recommended that an EHR Workgroup be stood in the successor that there is a need for this quantification around cost, cost of entry versus cost of annual sustainability, and getting some data and some good science around this, rather than an awful lot of anecdotes that’s not helpful for budget projections.

So with that and I just I throw that out as a means and a mechanism to get out of the cost piece. A recommendation let’s get centered back on the issue at hand, and that is the adoption of electronic health records and I’m going to add the word “effective” one of the speakers said “effective” adoption of EHRs and while meeting legal and regulatory requirements. We heard some real consistent themes here. I don’t recall which of the speakers talked about calling colleagues in other countries and the enormous amount of documentation that we have to do here in the United States that is not done in other countries. And I also am struck around losing the patient’s story consistently. We heard that theme. We heard the need for mandates being important around training, leaving no one behind and not allowing opt-out. We certainly have heard about the hardware issues. All of our speakers did a great job talking about the number of computers’ availability and the notion of data element reusability. So as we have been speaking, and speakers, as you’ve been contemplating your content versus what our charge is, does anyone have a recommendation that’s forming in your head that might be useful for us to make to AHIC here at the end of our work?

>> Craig Joseph:

This is Craig Joseph from Epic. One thing that I’ve heard in multiple from multiple physicians is that they’re under the impression that their notes need to say specific things in specific ways, or they won’t get credit. Coders won’t give them credit for making a certain diagnosis, and hence the DRG changes, and hence the amount of money that the hospital gets for that admission changes. And so they often give this explanation when I ask, “Well, why did you include a full list of all the medications that your patient is on? Did you do that in writing, on paper?”: “No, I never would do that.” “Well, why are you doing it now?” “Well, sometimes because it’s easier, because the project team told me how to do it.” But often I’d hear, “Well, you know, if I don’t pull that whole list in there, how do they know that I looked at the list of medications and I get credit for that?”

Same thing they’ll put labs in. They’ll put pretty much anything that they can pull. All of the vitals for the last day can get pulled into your progress note, and for patients that are in an intensive care setting, that can be a tremendously large number of vital signs. And so, you know, it’d be great if somehow the documentation that is required from physicians or any clinicians, really, could be clarified so that we don’t have, you know, coders arguing with compliance officers arguing with clinicians about, you know, “What is this note supposed to say?”, so that we can communicate our clinical intent and at the same time, you know, protect ourselves from audit.

>> Christoph Lehmann:

I’d like to echo this. This is Chris Lehmann. I think going back to the cost, I think the software costs are minuscule to the implementation cost. But then, you know, they also dwarf the cost of education. I was just doing the math. Just for our newborn intensive care unit alone 8 hours training per nurse and 50 nurses we’re talking the equivalent of three-quarters of a year of a programmer in form of cost right there.

So and then there’s an additional cost, which we really haven’t addressed. And the cost is, what does it do there is a potential risk for billing, as was just mentioned, you know, that and electronic documentation might not be able to fulfill the same requirements and might cause loss in revenue, which is a big cost concern for all of us.

So I think one of the things to look at is the documentation requirements as they are from HMS, and look at them and see if they actually might be a potential hindrance and an obstacle for electronic documentation, and that perhaps they might be something that need to be addressed in order to improve the overall acceptance of clinical documentation. I think part of the difference between progress and that, in this country and others, is the fact that we have these requirements that nobody else has.

>> Lillee Gelinas:

Karen, you’re staff to the Workgroup, and you’re hearing the discussion here. Do you have a path or a recommendation for us? Because I’m hearing a pretty consistent consensus around this issue of documentation.

>> Karen Bell:

Thank you very much, Lillee. I have been thinking quite a bit about it. I certainly have come to appreciate that the problems are far more legion than I think any one of us had thought a little bit earlier. I’ve been talking to a lot of hospitals around the country who have not yet started acute care documentation, because it’s such a daunting task. And those who have started it are finding that it’s, again, much more daunting than they initially thought as well.

I’m very impressed that the Group has shared a lot of very good ideas. And I’m wondering two things: #1, whether or not the Workgroup would be interested given the fact that we heard a lot in a very short period of time, would be interested in making a recommendation for HHS to move forward with a more specified panel, consensus, experts, bringing hospitals together to really go through these issues in greater detail, understanding to a much greater depth what the resource requirements are and how they can be met, understanding what possibly what could be done to address some of the big barriers. Particularly, the gentleman from Johns Hopkins just mentioned the issue about CMS. Is there a possibility that the Group might want to make a recommendation to revisit how CMS does its coding? I mean, there are a number of things that I think a new group could do in the future to really not only understand the issues better, but to solve them in a much more efficient way than build trying to build a wheel. How many hospitals are there, a couple thousand?

>> Lillee Gelinas:

Five thousand in America.

>> Karen Bell:

About 5,000 times over.

>> Lillee Gelinas:

So the notion, Karen, of a focused technical advisory panel that would assemble experts in this area of documentation and CMS requirements and was it a separate group that would handle this cost-of-adoption issue, getting our arms around that? Or is that also part of the technical advisory panel that you’re thinking we could recommend to HHS with

>> Karen Bell:

Well, I think one technical advisory panel could come together and do all of that. And I’m also I was very struck and as I’m sure many others were also on the dynamic between meeting templated structures to meet the needs for reporting and payments and the need to be able to really tell a patient’s story in a way that another clinician can then make the best decisions about that patient. I think that is a dynamic that plays out in virtually every setting. And I don’t know that everyone’s completely comfortable with it and would love to hear a lot more about that. And perhaps the technical advisory panel could help us understand that better, too.

>> Daphne Bascom:

And this is Daphne from the clinic, and I apologize. I’m going to have to step off and address an issue here. But if you’re going to include CMS, I would also recommend a representative from Joint Commission. Having just gone through an audit from both agencies here, a lot of the drivers for whether it’s a multidisciplinary point of care, present-on-admission documentation, and things that are augmenting the requirements for documentation from providers are being driven by external forces. And we need them to help guide us with regard to “How do we make this so that I don’t have to double-document, so I may leverage what other care providers may be documenting, and that we make it a comprehensive patient record and not necessarily indicate that it all has to be documented by one individual per se?”

>> Lillee Gelinas:

That’s a great point, and I know it’ll be captured in the minutes. Alicia Bradford here was also making the point that professional societies have their own documentation requirements as well and need to be a part of this Group. And that’s why a highly specialized technical advisory panel would probably serve us much better with the focus talent than what we’d need around the table to address these issues.

Did you want to go ahead (inaudible). You had an idea for

>> :

Related to templating, it seems like there’s a lot of recycling of efforts here on templates, perhaps in some recommendations surrounding a national repository for templates or something like that so people can start sharing instead of creating silos of information that are consistently redone. (Inaudible)

>> Lillee Gelinas:

And that would be something similar to what AHRQ does, maintaining evidence-based guidelines and a clearinghouse that we all tap into. And I wonder if there’s this notion of a clearinghouse for templates to try to reduce the duplication that seems to be occurring.

>> James Walker:

This is Jim Walker. We’ve made numerous attempts with other like-minded organizations to share templates. One of the things that makes them sharable is a clear federal consensus that this is evidence based and this is what is authoritative. If it’s not authoritative, it’s more effort to go through the clearinghouse than it is to just do it yourself.

>> Linda Fischetti:

This is Linda Fischetti. And two other colleagues to consider in this effort would be LOINC, of course, as a standard for naming convention for documentation, as well as the American Health Information Management Association, representing the health information management professionals. Thank you.

>> Lillee Gelinas:

Good point.

>> :

I think there are some recommendations that can come out also, in terms of structure of templating. One of the challenges, of course, relates to the different capabilities or approaches that different electronic health record technologies embrace. If they’re totally free text, then templating may be easy, but the data won’t be computable. On the other hand, something that’s highly structured may be computable but may not accommodate new templates entirely. And so, I think one of the recommendations somewhere along the line will be toward technology that allows the use of and I think the points on evidence-based template and validation are absolutely critical, and the comportment with enunciated and identified standard also critical, but the ability to accommodate templates and one can imagine that would be particularly useful and empowering in terms of the parallel activities going on, in terms of quality measurement and the ability to support quality management and the reporting.

>> James Walker:

This is Jim Walker again. One of the things that we are seeing is that, as there are clear standards and requirements for different kinds of quality reporting, most of which fortunately are evidence-based, vendors are becoming pretty prompt to understand that no one wants to buy a product that won’t help you collect that information efficiently and report it automatically. And they are moving at least many of them from, you know, “We don’t do content” to “We understand we have to provide that content, or you won’t buy this anymore.” And I think that’s part of the power of real standards is that once those standards have teeth regulatory and reimbursement teeth, there will be no problem with provider organizations like ours going to vendors and saying, you know, “How soon are you going to have this in? This is worthless to us if it doesn’t do that.” And vendors know how to respond to that kind of pressure.

>> Robert Juhasz:

This is Bob Juhasz with the American Osteopathic Association. I have two thoughts. One, I think it would be important to have some early involvement also in that technical advisory panel with the RUCK, just because, both from the standpoint of the costs that were mentioned I mean, I think capturing those from the standpoint of calculation of the payment side, as well as a physician work piece, because I don’t know that we’re really capturing all of the additional work that goes in with the, you know, voluminous information that becomes available once we’re using the EMR.

The other comment I would have is, pending the changes to the way that we do our documentations, the question (inaudible) is, can we actually adapt some of the technology, and can we make a recommendation from the standpoint of when we do click on a medalist or we click on, you know, reviewing labs, that there’s documentation that meets the requirements rather than having to reduplicate all of that documentation within a note, leading to the note load that Dr. Joseph spoke of?

>> Lillee Gelinas:

Well, we Jon, we have some good thoughts here. I’m wondering if we can get consensus from the Workgroup that Jon and I work with staff to create a recommendation around the technical advisory panel and the activities of that panel, and also a recommendation around something related to the template national clearinghouse Jon some made outstanding points that, you know, one of the issues truly is the variability of the different systems. But I’m just struck at this enormously important political time in our country, and we just keep hearing about how high health care costs and all of the things that are out there. Is there some contribution we can make that is very effective in our small scope of the world here that would contribute positively to that debate?

And I’ve also heard we need to craft something around this issue of costs. All of our panel today did a great job in helping us really understand the nitty-gritty around cost of adoption, cost of entry, cost of annual sustainability, hardware versus software, the unintended consequences of implementation. There’s almost a white paper that’s come out of this Workgroup today that could truly benefit the industry if we were to put together the tremendous expert testimony that we heard the various recommendations. And that may be another piece as well.

One of the reasons that we really wanted this panel before we talked about AHIC 2.0, of which Jon has been enormously involved in I’ve been involved in the transition committee piece, but he’s been even more involved, because I think we also helped the stage for AHIC 2.0 hitting the ground running with some very important issues to keep momentum and excitement going when we talk about electronic health record recommendations. So I want you to be everything that we’ve gathered here are a number of facts, and none of those facts are going to be lost, but it looks like three to four of these facts are some that we can use where we can have some policy implication around this and make recommendations going forward, if we work in earnest and then email back to the Workgroup your thoughts around a couple of recommendations. Does the Workgroup agree with that process step over the next couple of weeks?

(General affirmatives)

>> Peter Elkin:

Lillee, I was wondering if this is Peter Elkin.

>> Lillee Gelinas:

Hi.

>> Peter Elkin:

If hi, how are you?

>> Lillee Gelinas:

Good. Thank you.

>> Peter Elkin:

if you can sum up a lot of what was said in trying to create a partnership between the physician, the patient, and the electronic health record toward their best care and improvement of processes. It seemed to me that all of the different comments seemed to lead in that direction, you know, where the instead of being a passive entity, that the electronic health record could become more intelligent and be able to partner with a physician and the patient toward, you know, lifelong health and health care for the patient and, in so doing, improve processes for the physician. And that, I believe, has the potential to lead to both cost savings in terms of efficiencies of care and also safer practice of medicine, meaning the right thing is done more often. And that seems to be where a lot of the different recommendations have been driving us. I don’t know if everyone agrees with that.

>> Lillee Gelinas:

I think that’s a valuable part of the discussion. Particularly, as we look across the continuum of care, we continue to have this ugly elephant in the middle of the room, and that’s electronic health record adoption in the acute care setting specifically and where that fits in across the continuum, of course. But I’m glad you said that, Peter, because it’s all captured in the transcript, which is important going forward.

>> Peter Elkin:

Well, thank you very much.

>> Lillee Gelinas:

Any other thoughts related to this particular point in the agenda, Jon or Karen, from your perspective, before we move on?

>> Jonathan Perlin:

Let me just join you in thanking each of the presenters. It’s truly remarkable work. I too was struck that cost was not identified as a hurdle. And In fact, I suspect if we ask the presenters, none would go back. And I suspect as with the VA and the current organization, people would say, “We can’t afford not to do this.” But I think there’s a great deal to be learned, and I think all of us are suffering from parallel play. And so whatever can be consolidated, Lillee, Karen, into recommendations that allow national resources to be reused instead of reinvented, I think we all benefit.

>> Lillee Gelinas:

That was well-said. I called it “duplication,” but “parallel play,” I think, more describes the action around what’s occurring. We really need to think through that.

(Inaudible), you’ve just done a spectacular job and have done exactly what we were hoping we would be able to do to really drive in depth around this very meaty issue so that we could make some final recommendations to the American Health Information Community around EHR adoption in the acute care setting. I hope you will remain with us for the remainder of the Workgroup meeting today. If not, I do want to publicly thank you for your tremendous contributions and to everyone’s effort to make care safer, high quality, and more cost efficient, which certainly came through all of your presentations.

We’re going to move now to the portion of the agenda where we need to review our AHIC 1.0 Electronic Health Records Workgroup summary where we’ve been. This is the record of our journey: the 24 meetings, 38 recommendations to not imagine how much paper has passed electronically. I know my email box will go over its limit sometimes with some of those emails, so I know that it has not been for lack of tremendous sharing. But we do need to get the Workgroup consensus around the summary, and it’s most important as we transition to the AHIC 2.0 recommendations. And Jon, I know you’re listening intently for the recommendations that come out of this piece as well.

So I’ll turn it over to Karen. And the handout that you need says, “The EHR Workgroup Summary Overview” the slide or an overview of a larger document a Word document around our story. So Karen, can you help us walk through this, please?

>> Karen Bell:

It will, Lillee. Thank you very much. And I am actually going to do some slide skipping myself, because all of you know who you are, in terms of (inaudible) slide; and we’ve certainly talked about our vision and our charges before, as well as our key enablers in the privacy and security sector, the financial and business case, and the legal and regulatory area. And I’m already on Slide 4, so just so whoever’s managing the slides to catch us up to Slide 4. Thank you.

This slide and the next one goes into a little bit of detail, in terms of the description of what these key enablers are for widespread adoption. But again, all of these points have been made and discussed in detail in our previous meeting. So what these are is a representation and essentially a redefinition of the key enablers and what they mean that is reflected in the summary story that each of you have also seen.

What I’d like to spend most of our time on are the last few slides. So going immediately to Slide 6, where we talk about the key recommendations and status, we begin to look at the various enablers and look at some of the activities that have occurred over the course of the, believe it or not, 24 meetings that we’ve had together. There were as mentioned earlier, 38 recommendations altogether. And if you count the seven presenters that we had today, there’ve been 85 presentations that we have heard over the course of these 2 years. So this Workgroup has done a tremendous amount of work, not only listening and discussing in depth what we’ve heard, but also producing in very strong recommendations that are going to change the environment. There’s no question about that.

As far as the financial business case goes, the key ones here have to do with the recommendation that was made about a pay-for-performance program that, in fact, are rewarded physicians or incented physicians for the actual implementation and use of certified EHRs. And as you all know, the Secretary took that recommendation, and CMS subsequently launched the EHR demonstration project and announced that it would go live in 12 sites. And that was designed exactly as the Workgroup recommended. ONC, our own office, has been collaborating with the malpractice insurance industry and the Certification Commission to encourage premium reductions for those physicians who do adopt CCHIT-certified EHRs. So there’s been some progress there as well.

And then lastly, we can’t forget the results of the e-prescribing recommendations that were made in November of 2007, which are now included in the current Medicare update so that in 2009, there will be a bonus for physicians who are using e-prescribing. And by 2011, any updates in payment will be tied to the use of e-prescribing in the outpatient sector.

We’ve also made a number of recommendations in the technology area. The ones that I’m sure you all remember very well are the ones related to the development of harmonized standards, the HITSP standards that have found their way or are finding their way into electronic health records. And those include not only laboratory results but also the clinical elements involved in the emergency responder EHR. The executive order that went forth in August of 2006 I think it was was again a result of the initial recommendation about requiring that all federal agencies incorporate HITSP standards and interoperability standards in their various workplans.

Moving to the next slide, there are three more areas three more key enablers that we had identified. One of them was organizational. And there was a lot of good debate and good discussion on recommendations with respect to the workforce, which right now is certainly not up to the task, for widespread adoption. And those recommendations are in progress through HHS at the moment. And they’re ongoing active discussions on how to provide continued sup continual support to physicians or clinicians, particularly in small offices, who really have no idea how to even start the process. So those particular recommendations are moving forward.

You will recall that a number of workgroups made recommendations around privacy and security. And the result of that was the formation of another workgroup, the Confidentiality, Privacy, and Security Workgroup.

And then lastly, there are a number of concerns in the legal/regulatory arena, not the which not the least of which was revisiting CLIA and HIPAA guidance, particularly with respect to allowing access to historical laboratory information. So there’s been a lot of work happening in that arena also, and related to what is happening with our contract with the National Governors Association to identify and develop guidance for state leaders on these variations from CLIA and how to define “authorized person.”

So that, in a nutshell, is a summation a capital summation of a lot of work that’s been done that has led to significant movement and results moving towards the goal of widespread adoption of EHRs. Now, this doesn’t mean that we’re there yet. And so, there’s been an opportunity in a number of meetings that we’ve had and I will admit that we’ve not had a quorum for all of those, so they’ve not all been in the full-fledged meeting arena. But we have, in the opportunities for the future, looked at what could be done in the technological area again, the organizational area, financial business case area, and others. And these are the possible recommendations

>> Lillee Gelinas:

Karen, excuse me. I need to advance the slide here.

>> Karen Bell:

Please do. Thank you.

>> Lillee Gelinas:

It should be Slide 8 up. Thank you.

>> Karen Bell:

Thank you. And what the important piece of work that we need to do now is to go through these recommendations, make sure everyone is comfortable with them and if we feel that we would like to add any and we’ve there’s been some discussion about the two possible recommendations that have just come out of today’s panel, one on template management as evidence-based template management for acute care documentation, and then the other on the formation of a technical advisory panel to really understand and address all of the major issues associated with ACD in the hospital setting then this would be the formal set of recommendations that will move forward to the American Health Information Community at its meeting in November. It will be November 18.

So I’d like to just go through this list for now and then open it up for discussion. The first of these was to develop a strategy to grow and maintain the standardized coding and classification systems and standard tech terminologies/ontologies for adoption and uniform use of EHRs. This is a very basic piece of work. It’s important, whether it’s SNOMED or some of the other terminologies/ontologies, but to make sure that they are standardized and standardized not just in terms of the terminology, but how they are used and implemented in EHRs, both inpatient and outpatient.

Secondly, there’s a recommendation to align functionality, design principles, and usability of EHRs with best workflow and youth practices in multiple-care delivery setting. And I think this goes very much to what we were hearing in the panel. We certainly have certified EHRs for security, for interoperability, and for patient basic functionality. But when it comes to features that really provide the information necessary at the point of care or features that allow for some of these other needs that were described by our panel today, we really do need to understand this better. So this is in the technology area because of the usability aspects.

The third bullet was to ensure adequate standards in supporting technology for e-Rx, e-prescribing, including CDS. As you may recall, we talked earlier about having a certification process for electronic prescribing and the fact that, ultimately, there will be more standards that will be essentially recognized. And we’ll need to go into that process as well.

Third I’m sorry fourth is the continued certification in EHRs and other HIT technologies, relating, again, to the e-prescribing, but also including personal health records and other any other types of HIT that we’ll be developing over the course of time and then to develop an overarching strategy of how EHR adoption aligns with other types of health information technology. And in fact, we’ll have a little bit of discussion about that at the end if there’s still a significant amount of time.

In the area of organizational and cultural opportunities, the first was to develop support networks for the adoption, implementation, and use of EHRs tailored to specific care settings. And I’m also wondering if that’s a lot of that could be similar to what our technical advisory panel could be about.

>> Lillee Gelinas:

Yes.

>> Karen Bell:

You might want to reword that one a little bit. That’s my own little editing at the moment.

>> Lillee Gelinas:

Yes. Mm-hmm.

>> Karen Bell:

And then develop HIT support network for consumers and patients.

On the financial business case side, we were very concerned about the fact that the congressional business office and many others recognized that a tremendous amount has been done to look at the return on investment, to look at the quality improvement that goes along with HIT, but none of it’s been done in any type of a standardized format or a standardized methodology. And so, we thought that it would be very important to move the adoption agenda forward, particularly if we’re going to suggest that there will be other benefactors other than the delivery system from this. We need to have a really good standardized method of looking at cost savings, looking at return on investment, so that all of those who benefit from HIT understand their cost savings and can perhaps contribute.

>> Lillee Gelinas:

Karen, I just to stop you for a moment there, because we just had this robust conversation on cost. This cost seems to be around improved cost savings associated with health IT, and the cost discussion we just had is related to this but still a little bit different. So how would we position the cost recommendation that we have yet to wordsmith? It clearly would fit under the financial business case sector, correct?

>> Karen Bell:

I believe so, yes. I actually think, Lillee, that they are different enough that it would be an additional recommendation.

>> Lillee Gelinas:

Okay, okay.

>> Karen Bell:

Because this and the only reason I say that is, this one is designed to look at the cost benefit to multiple stakeholders to realign the business case. And what I think we were talking about earlier is to really understand what are the costs, because so many of them are hidden in the hospital sector.

>> Lillee Gelinas:

Right.

>> Jonathan Perlin:

But I also think that’s a tremendously important recommendation, in terms of really calculating the elusive ROI for an office or institution that happens to adopt electronic health records. But as we develop public policy, I think it’d be helpful to begin to come up with an agreed approach to calculating what should be included in costs and what should be captured as benefit. And I think it takes us back to the very beginning of AHIC and certainly the EHR Working Group with data from PETAC that showed a great deal of unnecessary replication of clinical services, as one area of loss, and a great deal of care that should have been given and would have provided for better outcome had information been available. And some of that’s documented in the PETAC report.

>> Lillee Gelinas:

Thank you.

>> Karen Bell:

Great point, Jonathan. Thank you.

>> Lillee Gelinas:

So go ahead, Karen.

>> Karen Bell:

I’ll quickly finish this up, and then we will open it to general discussion about how we might want to either add to, subtract from, or otherwise reorganize these. The last couple are pretty basic: to develop the business case and financial incentives for EHR adoption for multiple settings and that may be a little bit where our cost analysis might fit into the hospital. Focus and of course, we have to focus on the gap between small care delivery units and larger organizations. There’s no question that that seems to be widening right now, from the previous report that came out in July that the Blumenthal Group did.

We have a few others here as well. One was to develop a suite of recommendations to encourage support hospitals, EHR adoption and I think we we’re well on our way to that today and then form a group to coordinate and champion the adoption of e-Rx. We actually made that recommendation before Medicare came out with its pronouncement. So we might want to think a little bit more about the utility of that and what that actually might do.

So having pulled all this together at this point, it’s very dynamic. It’s open for lots of discussion right now, particularly in light of the new information we have today. I’d very much like to hear from everyone on the Workgroup in terms of anything we’ve missed, something we might be able to take off, or something we might be able to better clarify in terms of recommendations that will go to the AHIC in November.

>> Lillee Gelinas:

Do we agree that all of these need to, at the very least, be considered by AHIC 2.0 as part of continuing work in standing EHR workgroups under 2.0, at the very least? Do we have consensus around that?

>> Karen Bell:

I believe we do.

>> Lillee Gelinas:

Okay. It’s important for the minutes to note that we have consensus in the Workgroup for that.

Are there any to Karen’s point, anything that’s left out? I for one think it’s pretty comprehensive in knowing how much work is on this one slide. There is a lot of work on this one slide, but it’s important to find out if we missed something.

>> Karen Bell:

So what I would suggest, Lillee and Jonathan, is, we’ll work offline to have you incorporate the recommendations that were talked about a little bit earlier and send a new set out to everyone a new slide set out to everyone or just a new slide out to everyone for their final thoughts and comments. And if, hearing that (inaudible) once we incorporate those and get a final “Okay” from everyone, then they should be ready to go for November.

>> Lillee Gelinas:

Sounds good.

>> Jonathan Perlin:

Agree.

>> Lillee Gelinas:

So Karen, let’s move rapidly into the AHIC transition update and the AHIC 2.0 discussion. Jon, I’ll certainly call upon you a great deal. We don’t have a lot of time here, but you should have a slide deck that’s just entitled “AHIC Transition Update, September 10, 2008.” And if we can bring up the next slide...

I think, Karen, for most of this Workgroup, everyone knows what the AHIC successor purpose is. I certainly don’t see that that has changed. The next slide, around the scope of the successor, has not changed; and the next slide, which are the planning groups. I will officially turn the baton over to Dave since I’m here in Washington related to transition and the recommendations that we have. So perhaps we could pick it up to Slide 5, because a great deal has been done in the transition from A1 to A2.

>> Karen Bell:

That would be great. And I feel a little bit embarrassed presenting the slides here with Jonathan on the line.

>> Lillee Gelinas:

That’s okay. He’s one of the incorporators.

>> Karen Bell:

Jon, would you be willing to talk to these slides?

>> Jonathan Perlin:

Sure.

>> Karen Bell:

Thank you.

>> Jonathan Perlin:

Yeah. As you can see, actually, the list of first steps or that the organization is, in fact, now incorporated, and that’s means it is off the ground and officially is incorporated July 17. And the administrative aspects that are necessary to operate are all coming together. There’s work going on with a law firm to craft bylaws. I want to be very clear that the work is to reflect a very open process before membership p before planning groups you know, embrace to be sure that this is inclusive, open, transparent, consensus-setting consensus-generating, standard-setting organization. We’ll go ahead to the next slide.

And Laura Miller is the interim Executive Director. Full disclosure: She was really the Chief Operating Officer in Veterans Health Administration for a period of time, had retired from that a couple of years back, and is a very effective administrator. The board of directors meeting board of directors are being developed again, a process where nominations can be was convened, and nominations were accepted and I think around 150 in total and (inaudible) a group to ensure people that were nominated were also able to serve highly talented group of individuals. And the announcement of members selected as for board seats should be made at the Decem September 23 AHIC meeting. As the slide says, the first actual board meeting of the AHIC successor organization will be October 27.

One of the things that was very felt strongly felt was that the successor organization, moving to Slide 7, not be constructed in such a fashion that there would be a polarity between the you know, some predictable interest that one could envision. Indeed, this was really meant to be an organization with broad representation, representation of consumer-appropriate federal input; but an organization that brought together the public- and private-sector consumers and all members of the health community, including health consumers, to be able to help develop policy to expedite the adoption of electronic health records-related technologies and improved care. You see some of the lists of stakeholders as segments that were discussed but that are not being teed up as, you know, X number of representatives from this, that, or the other.

If we go to 8, maybe, Lillee, I’ll turn back to you, because you’ve been leading the Transition Working Group, so let me let you speak about the first recommendation.

>> Lillee Gelinas:

What the Transition Planning Group has done just, again, a tremendous group of individuals who’ve given of their time in order to lay a roadmap to 2.0. And clearly, the recommendations that we’re making reflect unfinished or additional activities of the seven AHIC 1.0 workgroups and the Ad Hoc CDS Planning Group. And this is totally based on their broad charges.

One of the key activities of the Planning Group and I think one of their greatest contributions, because you know how these workgroups just as our Workgroup began with a blank sheet of paper, it certainly felt like that with the Transition Planning Group, but coming up with recommended screening criteria that could be structured in a manner that prioritized criteria in order of importance. So as we considered the recommendation from the seven workgroups, we also put them through the screen of an initial screen, whether an activity was inherently governmental or had another home; and the second screen was, “Was that activity consistent with A2 core functions and scope, which is extremely important?” We then developed some final screens to help us with the recommendations that would go to the incorporator. And that had to do with whether they were mission and goal focused, whether they were budget focused or process or membership focused. So we hope what the Planning Group did was develop a set of screens helpful for the AHIC 1.0 unfinished work to pass through, but also a set of screens that the incorporators could use for other work that comes up in the future.

The final recommendations include a prioritized list of those transition activities. And the complete list of transition activities include those best taken on by other entities, including the government. And that’s what I was referring to as inherently governmental.

And I’ll just end there. I’ll just say that all the AHIC 1.0 workgroups have reported in to the Transition Planning Group. We do have their recommendations, and the Transition Planning Group does have their recommendations to get to the incorporators around the work that needs to continue. So back to you, Jon. (Pause), Oh, Karen. I’m sorry.

>> Karen Bell:

Okay. Jon, did you have anything you wanted to add?

>> Jonathan Perlin:

No, I just would note that Lillee has really done a heroic task, in terms of really helping channel recommendations from the work of AHIC. And at this point, in the course of AHIC’s successor, the work of Lillee’s Transition Group Membership Planning Group that I chaired, the Governance Planning Group that John Tooker chaired, the Business Sustainability Group that John Glaser chaired has come together in a nascent organization. And I think we’ll have the opportunity to really see how this organization will be able to meet the intended goals with the first meeting and more to be presented at the upcoming AHIC.

>> Karen Bell:

Well, I certainly take my hat off to both of you. You’ve done a fabulous job. It’s been a tremendous amount of work that’s been done. And it’s actually beginning to gel, and certainly through very hard work of both of you and your colleagues. So thank you, I think, from everyone else on the Workgroup as well.

>> Lillee Gelinas:

We can say, Karen, that the Transition Planning Group for A2 was considered the moving van. Peter Elkin and I and others that are on the call were driving the moving van. We know what went on the moving to go on A2. We know what had to stay, because it was an inherently governmental activity. And the moving van now here at the Manchester Building and will get loaded at 4 o’clock.

>> Karen Bell:

Great. Well, we certainly have a 4 o’clock deadline, then. Don’t we, Lillee?

>> Lillee Gelinas:

That’s right.

>> Karen Bell:

There’s one other piece of business. I know there’s

>> Lillee Gelinas:

Yes, the delivery system of options.

>> Karen Bell:

Right, but before we get to that

>> Lillee Gelinas:

Okay.

>> Karen Bell:

I think there is one other piece of real business we need to do, and that’s related to the timing of this Workgroup. As I mentioned earlier, the opportunities for the future will go to the November AHIC as a final set of recommendations to the current community. But then a decision needs to be made about this particular Workgroup and whether or not it would like to have one more meeting or how it would like to move forward, or whether this is in fact would be the last meeting of this particular Group, in which case there might need to be a little bit of discussion around that and how you would recommend the work continue representing the constituencies that you represent. This has been very much focused on the delivery system, getting electronic health records into the delivery system. So this Workgroup’s been very much focused on providers.

>> Lillee Gelinas:

So, Karen, I’ll tell you I’ll make a quick recommendation just to get us moving here. October 9 is a Jewish holiday, so we would need to reschedule that workgroup anyway. I heard loud and clear from this Workgroup that they would really like to see a technical advisory panel convene in order to get the experts around the table to our final recommendations forward. So I’d like to recommend that the October 9 workgroup meeting be canceled in honor of the Jewish holiday, that a technical advisory panel be stood, and that a our recommendation that would need to be in place in front of that Group would also have to consider dates that they would be available to meet electronically or otherwise. And I just want to commend them. I’ll let everyone know we have 20 people on the phone. We still have a quorum, so we still have full Workgroup input here as to what we should do with the October 9 date.

>> Karen Bell:

Open discussion?

>> Robert Juhasz:

This is Bob Juhasz. I certainly would support that. I think, you know, having that technical advisory panel meet and give some thoughts and recommendations to what we discussed today makes sense. As far as continuing for this Workgroup to continue to meet, depending it seems as though, you know, we’re looking to actually have that, you know, fold into AHIC 2.0. So, you know, I’m not sure whether or not we need to, you know, continue to process or you know, as that rolls out.

>> Lillee Gelinas:

I think the question that I have for all of you we certainly don’t know what AHIC 2.0 will do, in terms of how it will choose to stand up its workgroups or its steering committees or however they define them. But I think the real question is whether or not this Workgroup feels that it has met its charges to the point where the recommendations taken in toto essentially meet the charge, and therefore this Workgroup no longer needs to exist in any size, shape, or form; or whether there needs to be some type of a workgroup or, again, steering committee I’m not sure what they’ll how they’ll structure it for AHIC 2.0 that is focused on electronic health records or is focused on providers.

>> Robert Juhasz:

Well, I think that this is Bob again I think the opportunity there is to maintain some sort of structure until we’re sure that everything is functioning and you know, because there is a transition that will take place, and it will take time for the board to get up. In the meantime, there’s work that needs to continue to be done, I suppose, from that standpoint to make sure that what we have proposed continues to move forward. I’ll just use e-prescribing as an example. I we had a brief conversation online just about the fact that even though it’s been written into statute, as far as requirements and for reimbursement, there’s still pieces that we’ve talked about that haven’t been implemented and, I think, need advocacy, you know, to make sure that it really functions.

>> Lillee Gelinas:

Jon, see how this fits with what you might be thinking and everyone as well. We will make our final Electronic Health Records Workgroup recommendations to AHIC and the Secretary on November 18. So I’m wondering, given that we need the TAP to be convened we need our final recommendations wordsmithed that we have a very short Electronic Health Record Workgroup meeting, not a three-hour marathon but a very, you know, short session, last week of October or first 2 weeks of November we’ll have to do the calendar query to get us ready for the November 18 final recommendations to AHIC.

>> Jonathan Perlin:

I think that’s a good idea. I think that sounds like what if we want really honor the commitment to the TAP, then incorporate those recommendations.

>> Lillee Gelinas:

Yes.

>> Jonathan Perlin:

That’s the way to go.

>> Lillee Gelinas:

And I would ask if any of you on the phone now on the call now who are interested in serving on the TAP and have a particular area of expertise to offer if you will please email who are they emailing back to?

>> Judy Sparrow:

Alicia.

>> Lillee Gelinas:

Alicia Bradf Alicia Morton I’m sorry; she’s gotten married Alicia Morton your interest, because that will also help us a great deal as we look at convening a technical advisory panel.

>> Judy Sparrow:

(Inaudible)

>> Lillee Gelinas:

Judy Sparrow is suggesting October 29.

>> Judy Sparrow:

That’s a Wednesday.

>> Lillee Gelinas:

When was the first A2 board meeting again? I don’t have that right in front of me.

>> Judy Sparrow:

The 27th? (Inaudible, paper shuffling) October 27, yeah.

>> Karen Bell:

Well, let’s we’ll have to do the usual go-around to see if everyone can join and we can have a quorum. But I think that’s a splendid idea.

>> Lillee Gelinas:

I would say the 29th works for me, so...

>> Karen Bell:

Okay, great. I’ll send around an email.

>> Lillee Gelinas:

Send around an email, and let’s see what happens.

>> Karen Bell:

Okay.

>> Lillee Gelinas:

And your Co-chairs will assure that we’ll make it short. This is the final wrap-up. Put the bow on the package that’s going to go in front of AHIC on the 18th.

Karen, real quickly, the timeline for delivery system adoption Bob, I want to thank you for your suggestion. We have incorporated your suggestions into the document that we have here. The EHR Workgroup has not gotten them, but I wanted to tell you that it’s at the top. So if we could bring up Dr. Bell’s final presentation here, the timeline for delivery system adoption and take it away, Karen.

>> Karen Bell:

Thank you. And you will notice this is predecisional. This is draft, and it’s only for distribution to the EHR Workgroup. It’s being shown publicly. But it is being shared with you specifically to get your input and to get your edits and anything else that you can contribute to it, because it is very much work in progress.

The first slide basically predicates the strategic plan for adoption on something we stole from Maslow: Maslow’s hierarchy of needs. We were thinking about really getting widespread use of health IT out to the public. It really comes down to five big issues. First and foremost, obviously, we have to make sure there are principles and policies and protections that will make feel people feel comfortable that their information can be kept secure and confidential that their privacy is protected. That also means that some of those policies and security aspects are baked into product.

And product isn’t just secure. It has to be reliable. Product has to be interoperable. It has to have certain functionalities in it. And above all, it needs to be usable. It has to be something that is relatively intuitive and that the customer of the product mostly here in this situation, providers of care and patients themselves have to find that the products are usable for them meet their need.

Next up on the line is (inaudible) once we’ve taken care of those two issues, we still have a problem with finances, as we’ve talked before. If we solve that problem, then there are many other things that are necessary for patient and provider engagement. As we heard today and as we’ve been hearing for the last 2 years, if it’s not easy to do, if there are other barriers that are in the way, then it’s going to be very difficult to get widespread adoption. And then lastly, there’s an understanding of the fact that if we actually get to where we need to be, in terms of widespread adoption, it will be for the public good; and information can be used for research, information can be used for public health improvement and for surveillance a number of other areas.

So we’ve created this hierarchy of needs in terms of what it takes. And the reason that I start off with this is that you’ll notice that it’s color coded and that the next slide is color coded, too. This next slide is the one that’s very dynamic and very much the work in progress. It describes the goal that we all have: widespread adoption of EHRs by 2014, more than 50 percent of the delivery system. It includes the big chunks of the delivery system that we’re talking about. Large physician offices are very different than small physician offices. Large ones have over a 30 percent HIT adoption rate or EHR adoption rate. And the drivers there are going to be very different than the small physician offices large and small hospitals both. And nursing homes, again, have different needs in order to move this forward.

So we’ve put on here what we think and what we hope is a reasonable and this is where we’re going to need your input a reasonable approach to describing how we can bring the various segments of the delivery system along the time frame to get us to where we want to be in 2014. Along with that, you will see that there’s a lot of emphasis on some of the Maslow’s hierarchy or our hierarchy of HIT needs. We have HIPAA, in terms of privacy, not necessarily as robust as we would like it to be. But HIPAA is at least there in 2008, and we’ll probably need to do more moving forward.

But when it comes to the technology, we have HITSP standards in place that will certainly help. But the real big issue around the technology is going to be usability. So there’s a big chunk up at the top about usability which is not only important for widespread adoption and the delivery system itself but is going to be very important if, in fact, any type of federal or state support is going to be made available. And when you come right down to it, there’s a lot of discussion in Congress right now about how we can get federal support to the particularly small physician offices, but to the delivery system. And in order to do that, we want to make very sure that the products are what they are intended to be and will meet the needs of the delivery system. We also have heard from Congress, at least the Congressional Budget Office, that they need better analyses in terms of really understanding cost savings. So we built that in there as well.

In terms of really understanding how to help small physician offices, we mentioned a little bit earlier a program that will help move that process along. And it’s those that’s very much related to the workforce and the workflow issues that are going to drive both hospital and nursing home sectors. Cost is a big issue in hospitals and nursing homes. But many of them have recognized they have to bite the bullet. They have to do it, even if it is 5 percent of their operating budget. But in so doing, they’re just they’re bumping up against huge workforce issues and big workflow issues, so that helping to solve those, we thought, would be very important to meeting those goals of getting those delivery systems on board.

Reimbursement reform, we recognize, is going to be very important as well. Being able to provide clinicians reimbursement or payment for their time and expertise independent of where they are where their patients are in the virtual care environment is going to be a major driver, as will be providing payments for the actual reporting of data, independent of where that goes to, whether it’s for research purposes or quality improvement or for public health.

So we put these up on the slide. This is our first flush of this. I know that time is running short. I also know that we’re going we are going to be meeting again. But this Workgroup has been living and breathing this these issues for the last 2 years. I will share with you that the Chronic Care Workgroup on Monday really wanted us to push. And so, the issue on reimbursement form is being pushed back into 2010/2011. They really felt quite strongly that waiting until 2011/2012 is far too late for that. So I’ve already gotten good feedback from that workgroup. But frankly, you’re all the ones that looked at all these issues, that helped create these issues, and you’re the ones that I think we’re going to be most dependent upon for input on this.

Ultimately, we would like to present this to the AHIC in November. We may also be presenting it in other venues in November AMIA and a few other places. But it really is very, very much dependent upon all your input, so would love to hear back from you offline, and then we can bring this back for discussion at the 29 on the 29th. But so again, in the interim, we need your input very, very intensively on this.

I will share with you that there’s one more slide that’s in this packet, and that is about the adoption of HIT by the consumer. There’ll be a lot of discussion on this one at the Consumer Empowerment Workgroup. But I would like to also share it with you, because we’re all consumers of health care, if we’re and we’re all patients. So when we think about how we can engage the patient sector and engage consumers into really using HIT, we’ve put together this particular approach, based on a lot of work that we did with the Consumer Empowerment Workgroup as well. You’ll note and I’d like to call your attention to specifically the fact that this particular slide has a gray box in it which talks about widespread adoption of information in the delivery system, because the belief is that or one of the beliefs, or one or certainly a belief is that in order to get really consumers engaged in using their own health information, they have to have access to it from the delivery system. So we put that box in there, too.

None of this is going to be published just net yet. It is not available online anywhere. It’s just for open discussion and for your input. And we’ll talk about it more at the next workgroup. But we really, really would appreciate your taking a few moments to think it and get back to us.

>> Lillee Gelinas:

Karen, just a couple of things. It was not intuitive to me that the colors in the triangle mapped to the next two slides. So a legend, especially when we do release this publicly and I think it should it well maps out the different points in the process if there’s some way that there could be the color coding if this was ever printed in black and white, then it just would not have the same interpretation.

The second is, I really am wondering if to me, this mapped extremely well to our EHR Workgroup’s story. And I could almost see an asterisk after or in each of these boxes that append back to a presentation or discussion that we had at the Workgroup. When we think about broad consensus and how important it is to get everyone involved and to note the hard deliberation of this Workgroup with 85 presenters Alicia, is that what you said? Is that 85 presentations? to note that the boxes reflect a discussion and a segment of work of the Workgroup. So if there was a way to note that, yeah, we talked about HITSP in our operability for the lab, you know, e-Rx when it strengthens the evidence that’s behind this particular grasp and finally, at 2014, some type of way to note President Bush’s executive order in April 2004 that really started this whole thing, which is again, anyone that picked this up that had not been close to the work would not know, “Well, why did you end at 2014? Why is this going from where it is to where it is?”

>> Karen Bell:

Absolutely. Your points are excellent, Lillee, as always, and I really do appreciate them. And we will certainly put a lot more effort into the finer points of describing all of this, once we feel a little bit more comfortable that what we have down here, in terms of timelines and blocks and interdependencies because this is really about priorities and interdependencies and timelines we want to make sure we can get that as close as possible. And then we’ll come back to you for a lot more refining on those points, which are absolutely well-taken. So thank you very much, Lillee.

>> Lillee Gelinas:

I’d begin in October 2005, when we began, but because we Alicia and others have spent so much time on the story.

Let’s move now, please, if the operator will bring the public in. We need to move to public comment and hope that we have had some others that are listening and are wanting to give us some input, ask a question, or give us a comment.

>> Alison Gary:

For those that are online, you see a slide on how to call in to comment or ask question. If you’re already on the phone, you can just press star-1 on your phone now to comment. Any last-minute comments while we’re waiting for the public?

>> Lillee Gelinas:

Just emphasizing that, again, Judy Sparrow will send out an email to reschedule our October 9, 2008, Electronic Health Records Workgroup meeting later and closer to the next AHIC meeting that occurs on November 18. After the next AHIC is September 23, and then the final AHIC meeting or the second-to-last AHIC meeting is November 18. Technically, there are three other AHIC meetings on the books: September 23, November 18, and December 9. Operator, any public comment?

>> Alison Gary:

No, we don’t have any comments from the public.

>> Lillee Gelinas:

Okay. Jon, I had a couple of wrap-up points here, but would you like to make a few comments as we conclude?

>> Jonathan Perlin:

Just very briefly want to thank all the presenters for terrific input. And I think our task concludes one chapter but opens another. And, you know, I think back to the 2014 and know that, of course, everything will evolve, but, you know, there was an aspiration to make electronic health records available to most Americans by that date. And I think what was so important about the presentations we heard today was that, across a range of institutions with more modest resources than others, cost was not the hurdle. In fact, you know, due diligence before I think a statement that unified all is that they couldn’t afford not to implement the electronic health records. I think that’s really the broader issue is that as we look at the challenges we face as a country in terms of Medicare, in terms of international competitiveness, we can’t afford not to do it. We owe everyone (inaudible) quality care, but we also owe ourselves to remove non-value-added costs from the system. And that can be supported substantially with electronic health information.

So we that will be really that is the task for the AHIC successor organization is to help continue and even accelerate the adoption of information technologies toward improving the safety, quality, and efficiency of care. Thanks.

>> Karen Bell:

And Jon, we have great confidence in you. We’re so glad you’re an incorporator of AHIC 2.0. We know you will carry both the broad sense of AHIC as well as the tremendous work that the Electronic Health Records Workgroup has done into the work, decisionmaking, and prioritization of A2.

So with no other business to come before the Workgroup, I’ll call the meeting adjourned. Bye-bye, everyone.

(General thanks and farewells)