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Electronic Health Records vs. Niche Software that is actually useful for Family History. Kevin S. Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Bruce Lin Project Director, Family History for Prenatal Providers - PowerPoint PPT Presentation
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Kevin S. Hughes, MD, FACSCo-Director, Avon Comprehensive Breast Evaluation Center
Massachusetts General Hospital
Bruce LinProject Director, Family History for Prenatal Providers
Manager, Public Health InitiativesMarch of Dimes
Electronic Health Records vs. Niche Software that is actually useful for Family History
The EHR has tremendous promise as a means of decreasing workload, decreasing
cost and improving quality of care
Reality• EHRs decrease productivity or are neutral• EHRs have not been shown to increase quality• EHRs have not been shown to decrease cost
Consider what Jonathon Bush (AthenaHealth) calls the ‘Cash for Clunkers’ program. Doctors have to
be paid to install these EHRs
The EHR has tremendous promise as a means of decreasing workload, decreasing
cost and improving quality of care
EHR HIT has tremendous promise as a means of decreasing workload, decreasing
cost and improving quality of care
•Apply Algorithms/Guidelines to patient data
•Identify best course of action
•Results displayed as intuitive Visualizations
BRCAPRO Mutation Risk 25%
Suggest Genetic Testing
Facilitates best action as part of workflow
Clinical Decision Support
EHR Issues
“Computerization hasn't saved a dime, nor has it improved administrative
efficiency”• 4,000 hospitals 2003 to 2007 • Computerization
– Weak correlation • Quality for MI
– No correlation• Cost savings• Improvements in administrative efficiency• Quality for pneumonia• Quality for heart failure• Overall quality (MI, heart failure, pneumonia)
Himmelstein, The American Journal of Medicine (2010) 123, 40-46
EHR and productivity varies by specialty100 internists, pediatricians and family practitioners
• 25 to 33 percent drop in MD productivity
• Over time
– Internists slightly above original productivity
– Pediatricians /family practitioners never recovered
Hemant Bhargava, UC Davis Graduate School of Management
Quote from a breast surgeon beginning EHR use
• …our productivity is down 28%
• I am the highest paid transcriptionist in the state
• Each cancer patient chart takes me apprx 1 hour
• For the first time in my career, I turned down an add-on patient
Currently: Paper + memory
Patient completes paper form
Reviews data using memory of guidelines
Orders Genetic Testing
Documents and Orders
EHR: Paper + extra work + memory
Patient completes paper form
Reviews data using memory of guidelines
Staff enters data into the EHR
Documents and Orders
EHR
Generic InterfaceMostly
Filing CabinetOr
Document Management System
SmallDatabase
MedsAllergies
Same interface for every Specialty
EHRMammography
Pathology
Generic
Anesthesia
Cardiovascular
IT ≠ EHR
Role of the EHR in Family History…close to non-existent
While EHRs do poorly for most aspects of medical care, they are worse relative to family history and
genetics
Health IT
• EHR– Designed to manage the entire
spectrum of medical care• Created by large corporations
– E.g., NextGen, Allscripts, eClinicalWorks, Misys, Centricity, Eclipse, LMR
• ‘Niche’ Software– Designed for specialty areas
• Homegrown or developed by small vendors
– E.g., My Family Health Portrait, Jameslink, GREAT, Progeny, HughesRiskApps
Health IT• EHR
– Designed to manage the entire spectrum of medical care
• Created by large corporations
• ‘Niche’ Software– Designed for specialty areas
• Homegrown or developed by small vendors
Health IT and Clinical Care
• EHR
• ‘Niche’ Software
Notes
Lab
ProblemList
Path Reports
Meds
Allergies
EHRs are limited to major areas
Notes
Lab
ProblemList
Path Reports
Meds
Allergies
■
Risk
Ө Pedigree
Θ Family History
■
Genetics
Adding new features for small markets is expensive
Every EHR must rebuild the same basic route
EHRs have difficulty improving • AHIC Core Data Set
– Published 2008– No EHR Vendor has adopted it
• HL7 Pedigree model for interoperability– Approved 2006– No EHR Vendor has adopted it
• Family history upgrade to EHR at my institution– submitted 2006– slated for analysis 2009– Implementation 2013 or later
The American Health Information Community (AHIC) Personalized Health Care Workgroup
Recommendations to Secretary 2007
… Modular family history tool… collection of family health history within the EHR…messaging of … information to a variety of richer … tools that perform risk analyses… results of … calculations … returned to the EHR … for curation
EHR 2
NicheSoftware
Niche/Modular Software Innovative approaches to data entry
Patient data entryClinician data interface
Innovative approaches to CDSRisk Algorithms/GuidelinesVisualization appropriate to userPedigree drawing
EHR as a repositoryCore data setInteroperable
Testing and iteration possible
EHRs and Niche Software
EHR vendors say:• Wait for the EHR to do this
• Niche software is not needed
• EHR should not exchange data with Niche Software
Current EHR Future EHR
Monolithic Interoperable with multiple ‘Specialty Specific’ systems
Family History CDS
AlgorithmsKnowledge
Base
Vendor 1Vendor 2
Vendor 3
Family History CDS
AlgorithmsKnowledge
Base
Family History CDS
AlgorithmsKnowledge
Base
Monolithic Approach150 Vendors create 150 different CDS approaches to the same problemCurrent EHR Future EHR
Monolithic Interoperable with multiple ‘Specialty Specific’ systems
CDS
Hereditary Risk Identification
Click open 4 screens
BRCA1+
Hereditary Risk Identification
Hereditary Risk Identification
Typical EHR
HughesRiskApps
Better workflow
Reviews Report & Pedigree
Reviews suggestedmanagement Documents and
Orders
Patient educatio
nal material
sClinical
Decision Support
Patient enters data Tablet PC
iPadWebsite
Clinical Decision Support
EHR
Current EHR Future EHRDecrease productivity or neutral
Increase productivity
Mostly document repository Database
Mostly free text Structured data
Data entered by staff or provider
Data entered by patient, staff or provider
Generic interface Specialty specific interfaces
Rudimentary CDS/Drug-Drug interactions
Effective CDS for multiple specialties
View isolated transactions View consolidated information about a given problem
Proprietary hidden information
Open access to patient data
Monolithic, barely intraoperable
Interoperable with multiple ‘best of breed’ systems
Clinical Decision Support
AlgorithmsKnowledge
Base
HL7
Vendor 1
Vendor 2
Vendor 3
Current EHR Future EHRMonolithic Interoperable with multiple
‘Specialty Specific’ systems