Electronic Health Records and Data Standards2012

Electronic Health Records and Data Standards2012

Electronic Health Records and Data Standards2012

VA Health Informatics 101[1]

Industry Expert Perspective Series

Electronic Health Records and Data Standards


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Electronic Health Records and Data Standards2012

Slide 1

VA Health Informatics 101 Industry Expert Perspective Series

(Patricia): Hello, VA Health Informatics 101 Learners! It is pretty thrilling to be addressing you today. I am Patricia Dombroski, the Director of the Life Science Informatics Center at Bellevue College. We are thrilled to be bringing a series of National Experts to you in real time to have an opportunity for you to have interchange with them and to advance your knowledge in this wonderful pursuit.

This is the first, as Chase let us know, it is the first in a series of live webinars with nationally recognized health informatics leaders. It is called Industry Expert Perspectives for good reason. The webinar and all of the training that you are participating in is funded by the Office of the National Coordinator for Health IT, which is part of the U.S. Department of Health and Human Services, and I would be remiss if I did not mention your very excellent world class VA Health Informatics Initiative Team. They have been absolutely instrumental in all of our efforts including this webinar and the course itself. We hope you are enjoying it, number one.

For the inaugural webinar today. we do welcome Ernie Hood, as Chase said, and you can find his biography on your class site. Just click on the link. He will tell us a little bit about his background in just a moment. Today's topic is electronic health records and data standards, and what we would like to do in this webinar and the subsequent ones is just keep it conversational. Our goal here is not a stiff lecture but rather a conversation, and we want to connect you with the people who are creating a new framework for health IT in the United States. So it is just a great opportunity, and we are delighted to connect you to these industry leaders. Let us get started.

Ernie, it is a pleasure to have you here and probably the thing that we are most wondering about is many of us know who you are, of course. You are by very definition a national leader in health informatics, but maybe you could tell us how you got there.

(Ernie): [Laughs] Well, that is a great question. Thanks Patricia. I am honored to be joining this program. This is such a vital need right now to have IT professionals from health care in this program intended to grow those kind of professionals. It is just incredibly important to us. I am excited to be here.

So how did I get started. I am embarrassed to admit that it has been this long, but I started in information technology way back in 1980. I actually started out working in the oil industry, and in 1991 I moved from the oil industry into health care, which was a wonderful move. If you have ever worked in an industry like the oil industry, it is all about making money and it is not really about helping people, and that is the wonderful thing about health care is health care is focused on helping people. I have probably done or managed everything that is possible to do in a health care information technology department at some point in my career. So that is really my background. I have worked on pretty much everything there is in health care IT. And the organizations that I have worked for had full health plans so it played the of role of being a payor as well as being a care delivery organization.

(Patricia): So, it is one of the biggest cooperatives in the United States.

(Ernie): Oh, absolutely. And in fact it is about 900 physicians and about 25 different medical centers spread throughout the state of Washington, and actually consumers are in charge of the organization. The patients run the shop.

(Patricia): [Laughs] Yeah, and then you made a switch recently.

(Ernie): Yes, I just started working with the Advisory Board Company. We are a consultancy that provides best practice expertise on health care as one industry and then education as another industry—so two of my passions rolled into one thing. I have to say that in both cases both industries suffer from this lack of ability to propagate and find best practice. So it has been real exciting.

(Patricia): Great, well, we should just dive in. We are going to be talking about electronic health records and data standards today.

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Electronic Health Records and Data Standards2012

Slide 2

Some Health Care Basic Numbers

Just at the very baseline many of our students are very conversant with electronic health records but some are not. Maybe we could talk about the components that make up an EHR (electronic health record).

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Electronic Health Records and Data Standards2012

Slide 3

How can IT help Health Care Electronic Records Physician Decision Support Patient Safety Research Quality Improved Coordination man wearing medical scrubs(Ernie): Sure, I am going to be rolling through a presentation here.

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Electronic Health Records and Data Standards2012

Slide 4

Electronic Health Records Components

This is something that I have pieced together from a lot of different sources, and so you will forgive us if we hop around the presentation a little bit. If you look at the slide, you will see we have broken down the components of an electronic health record. The simple thing starts on the right-hand side there, you see medical records.

So, fundamentally an electronic health record is about having a database where you can store medical records. Things like clinical documentation, diagnosis, a problem list, a medication list, an allergy list, immunizations, test results–all of that. It is a database designed to hold and store all of those things. Now the tricky part with electronic health records, if you look over on the left, is the workflow components.

It is not good enough to just have a database. Electronic health records need to assist the physician in creating the documentation and in enabling workflow to go from one caregiver to another. In dealing with capturing orders and ensuring that safety checks are run and supporting what are called clinical guidelines and clinical decision support, as well as population management.

We know certain care protocols apply to say diabetics, and to have a registry of diabetics can enable the physician to take better care of those patients.

(Patricia): And there is a lot to the storage of electronic health records. Can you talk a little bit about the various approaches?

(Ernie): Ahh, yeah. A little interesting thing here. Initially health care records were paper based, not too surprising, and so the move from paper-based electronic has been a long journey. There is an approach to having electronic records where basically you take the paper, and you take a picture of it. You scan it, and then you store the scans in the database indexed generally with a pretty simple index.

And in order to find the document that they want, the physician has to find the index and then open the document as if it were say a TIFF file or a JPEG. Another method is to have what are called Blobs, so a large binary object. So things like a on-line radiology system, known in the industry as PACS [Picture Archiving and Communication System], are good examples of these things. It has a lot of digital information presented in a giant electronic blob, not your classic database.

And then the third aspect—this is the one that everybody really strives for–is where the discrete data is in a database and is accessible. So instead of taking a picture of that medical form, the providers are actually able to access the discrete data elements within the form as if they were ”as fields” in the database.

(Patricia): Interesting, so…

(Ernie): In modern health care, most providers today that do have electronic records have what is known as a hybrid record where all three are combined in the database.

(Patricia): And for us sort of health informatics nerds, it seems like it is a foregone conclusion that electronic health records are ubiquitous. But really, if you could give us a reality check, how common are EHR's in the industry right now?

(Ernie): Well, I will bring up the HIMSS database here.

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Electronic Health Records and Data Standards2012

Slide 5

Stages of EMR Adoption

HIMSS is an international organization, the largest (Health Care Information Management Systems Society is what it stands for), the largest health care IT association in the world.

(Patricia): And if I might add, you are the current president of the Washington state chapter of HIMSS.

(Ernie): Yes, I am. Thank you. And so, HIMSS created this maturity scale or a model for use of electronic medical records. And that is what you are seeing in front of you now. Its scale goes from level 0 to level 7, with, as you would expect, increasing difficulties to achieve each level.

So at the most basic level an organization would simply have ancillary systems, so a lab system, a radiology system, and then at the most sophisticated level, they are not only doing physician order entry, which is what CPOE stands for, and closed loop medication and online documentation, but they are actually able to do data sharing through continuity of care documents, which is what the CCD stands for.

So, the numbers–and this is quite interesting to me—back in 2000 nobody would have been at level 5. Those would have been zeros. And today in 2011 you can see in Q1 we had 1% of hospitals were at level 7, in Q2 1.1%. Not a very dramatic increase, but in one quarter for that number to budge is pretty impressive.

The big thing to notice though is now at level 3 we have got 48.4% of hospitals reporting level 3. And you can see the numbers are increasing dramatically. I think what is going on here is related to a large degree to the stimulus package, to ARRA (American Recovery and Reinvestment Act), which has provided funding for providers to implement electronic medical records, and between that and the huge debate we had over the last few years over health care reform, I think the entire industry has gotten the message you need to get more efficient, and one way to get more efficient is we need to implement electronic medical records. And that is what you are seeing here.

(Patricia): I can see that from the numbers that it looks like the large number of people are on the road. We are moving in the right direction. How about those that have not yet taken the first step? What are some barriers to adoption?

(Ernie): Great question. So, the first one is that, one of the toughest, is cost. Electronic medical records are not cheap to implement. The organization that I was with, Group Health, we actually spent 40 million dollars implementing our electronic medical record.

Now, Group Health is a very large organization, as I said 900 physicians, and that would not be your typical price line for a provider group to implement, but from a magnitude standpoint it is a big number, and it is almost always in the million plus kind of ballpark. So it is a very daunting cost equation.

The second issue is, frankly, caregivers themselves when you move to electronic medical records. Somehow, the information has to get into the computer, and how the information gets into the computer is through the physician typing it in to the computer. Many physicians are used to a world where they have a bubble chart, and as they treat the patient they document by filling in things in a bubble chart and scribbling some notes and they hand it to somebody else who types it in.

That is great for record keeping, but if you are using the computer to assist you with things like clinical decision support, if you expect the computer to warn you that these two meds you prescribed are going to conflict with each other, or if you are expecting the computer to warn you that the patient is allergic to this med, or if you want the computer to be tipping you off that this is a diabetic that has not had a foot exam in 2 years and maybe you should do one, then the physician has to be doing it. And there is the rub. It is new extra work for the physicians that they were not doing before.

(Patricia): Then the flip side of that is what is really accelerating the trend. You mentioned the ARRA funding of course, and that will last for another couple of years and then it actually turns into more of a penalty phase or a disincentive. But what else is accelerating adoption?

(Ernie): Yes, so a very exciting thing that I have been pleased to see happen is as younger physicians move into the workforce, their entire framework of how they expect to work and to live is radically different from their older predecessors. They have never typically worked in a paper-based world. Their expectations are set by things like online banking and Twitter, and so to my amazement and satisfaction in moving to the workforce they are actually demanding electronic medical records, and it is completely irrational to them that they cannot use tools like instant messaging to communicate with each other.

So, they have moved into the workforce and taken a bigger and bigger percentage of the current physician workforce. They are transforming things. So I think culturally as well as through government-inspired changes, we are seeing a movement here that is really picking up steam.

(Patricia): Full disclosure: we have been graced with Ernie Hood at Bellevue College as an instructor I think twice now? Is that correct?

(Ernie): Oh, maybe three or four times.

(Patricia): You are just a superlative instructor, and our students are so enthusiastic about your classes. It has just been a wonderful experience for all of us. When you teach here at Bellevue College, you often start with a focus on history, that is, the paper record, rather than diving into the electronic health record. Why is that and why do you think it is so important for students to know and have that grasp on what paper records are?

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Electronic Health Records and Data Standards2012

Slide 6

Billing & Reimbursement

(Ernie): Well, let us, start with this slide here, is just a little facetiousness , but I think that this kind of puts a point to it. It is a little cartoon where there is like an operating room theater and a person sitting at a desk and the instructor says now watch carefully as Dr. Keeler staples the insurance claim form to the patient’s admission form. This is humorous, but the fact of the matter is that medical records started with an eye towards billing and documenting frankly why people died.

They were not started with all of the quality interests that we have and care management interests that we have today. I think it is really important that students understand the basics of the paper record because that is what is trying to be stored in the database.

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Slide 7

Data Standards

So, on the slide that you have in front of you here, I have listed some handy sources for data standards, and these are standards that are used in paper records. So CPT4, HCPS, ICD-9 codes—that is how a physician will document not only a diagnosis but the services that they have provided to a patient.

ICD-10, which I am sure you have all heard about, is a major transformation in how those codes are used, but it is a complete set that not only offers diagnosis but also service documentation codes. And then SNOMED covers problems and diagnosis and LOINC is designed for lab information, and NDC is for pharmacy medication type data.

Now those are, that is the basis, that is what people are trying to document in the electronic medical records, that the tools or the standards used for recording such documentation,

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Electronic Health Records and Data Standards2012

Slide 8

Technical Data Standards

HL7 and X12 are the most common, and listed here you got again some links for those technical data standards.

I recommend to students that you keep those in your back pocket because so few people actually go to source data. People in health care in particular have a tendency to rely on someone else to represent what something says rather than go to the source. Here is the link to the source.

(Patricia): Well, that is great and we will definitely include that in the class links as well because we have a rich library of supplemental information. You have talked about the paper record standards and the electronic standards, any further examples you wanted to mention? No, okay. Well, I will keep it up.

So then there is a whole other side to the electronic health record, and that has to do with the direct patient information and Group Health, which you were most recently CIO of, is certainly a leader in patient portals.

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