WHY EMR??

Dr Aloke Mullick, MS (Surgery)

Business Safety Quality
CPOE Evidence
Revenue
base at
leakage BCMA POC

Data CDSS
analytics Research
for mktg CCR
 Definitions
• EMR (Electronic Medical Record) – the set of databases (lab,
pharmacy, radiology, clinical notes, etc.) that contains the health
information for patients within a given institution or organization
• CDSS (Clinical Decision Support System) component - software that
makes relevant information available for clinical decision-making
(clinical data, references, clinical guidelines, situation-specific
advice)
• CPOE (Computerized Physician Order Entry) component – enables
clinicians to enter orders (tests, meds, dietary, etc.)
• CCR (Computerized Clinical Reminder) – just-in-time reminders at
the point of care that reflect evidence-based medicine guidelines
• BCMA (Bar Coded Medication Administration) – a software driven
approach to full cycle medication management, from ordering, to
order processing to medication administration
How safe is healthcare delivery…..

HEALTHCARE SAFETY &

QUALITY
How safe is healthcare delivery
DANGEROUS ULTRA-SAFE
(>1/1000) (<1/100K)
100,000 HealthCare
Driving
Total lives lost per year

10,000

1,000
Scheduled
Airlines
100
Mountain Chemical European
10
Climbing Manufacturing Railroads
Bungee Chartered Nuclear
Jumping Flights Power
1
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

Source: Berwick, D.M.

 “To Err is Human…”
Top 10 Causes of Death in 1998
1 Heart Disease 724,269
2 Cancer 538,947
3 Stroke 158,060
4 Lung Disease 114,381
5 Preventable Medical Errors 98,000
6 Pneumonia 94,828
7 Diabetes 64,574
8 Motor Vehicle Accident 41,826
9 Suicide 29,264
10 Kidney Disease 26,295
 Need for EHR/CDSS: Medical Errors

Estimated annual mortality

Air travel deaths 300
AIDS 16,500
Breast cancer 43,000
Highway fatalities 43,500
Preventable medical errors 98,000
(1 jet crash/day) 98,000
Costs of Preventable Medical Errors:
$29 billion/year overall
Kohn LT, Corrigan JM, Donaldson MS eds.
Institute of Medicine. To Err is Human:
Building a Safer Health System. Washington, DC: NAP, 1999.
1935 2016
 The great advance……..

1935 2016
• Physicians spend 38% of their time writing chart
notes.
• 35-39% of total hospital operating cost are spent
on patient and provider communication activates.
• Medical records could not be located 30% of the
time when needed.
• Once found the volume of information in them
was often so large that it became unmanageable.
• It was shown that simply organizing information
flow sheets accelerated retrieval of needed data
at least 4-fold.
 Paper trail………………..
WARNING, our physicians and nurses are attempting to use
antiquated manual record-keeping systems and their own limited
memories in an often futile attempt to deliver a complex set of
services without error. The logic of these human beings has
been tested incompletely at some point in the past, but we offer
no warranty expressed or implied that any individual decision
made or action taken will be provably correct. Moreover, we do
not know the effect of aging, distractions, overwork, and failure
to communicate on the overall care you will receive. Because we
do not take a systems approach to health care services, by
signing this consent you agree to participate in this admittedly
error-prone and potentially life-threatening activity.

Courtesy: Charles Safran, MD

 Quality chasm……

“98,000 hospital patients • “Virtually every patient

die every year in the experiences a gap between
US alone because of the best evidence and the
adverse events” care they receive”
Institute of Medicine, 1999 – Institute of Medicine, 2001
 The call……

Create systems of care that are

safe, timely, efficient, effective,
equitable, and patient-centered.
Institute of Medicine
 Case for CPOE

CPOE can reduce

prescription CPOE Systems by
errors by up to 70% reducing medication
errors,
Leap Frog Group
can pay for themselves
in 26 months
Massachusetts Tech Collaborative
and New England
Healthcare Institute
Adverse drug events………

The most
dangerous
device in
healthcare
What will you choose….
OR THIS….
Order sets
BCMA….

• Right Medication
• Right Dose
• Right Route
• Right Patient
• Right Provider
• Right Time
 Case for CDSS

20,000 biomedical journals

500,000 indexed in PubMed annually
> 150,000 articles per month
6,000 articles a day

Medical References Services Quarterly

2007;26:1-19
 More Data Over Genomics
the Last 5 Years
Digital Pathology
Than Previous
Digital Radiology
40,000 years
Combined E-Health Initiatives/Linkages

40,000 BCE Electronic Medical Record

cave paintings
bone tools 3500
writing
0 C.E.
Digital Cardiology
paper 105
1450
printing
1870
electricity, telephone
transistor 1947
computing 1950 Late
1960s
1993
The Web
1999
2015
Source: UC Berkeley, School of Information Management and Systems.
 Catching up…….
Finish medical school and residency
knowing everything

Read and retain 2 articles

every single night

At the end of 1 year

1,225 years behind W Stead. JAMIA 2005;12:113-20 ,
Alper BS, Hand JA, Elliott SG, et al.
J Med Libr Assoc 2004;92:429-37.
 Clinical reminders

Clinical
requirements
Dia betes Pa tient Dialog for
processing multiple reminders:
• Diabe tic Foot Care Education
• Diabe tic Foot Exam
• Diabe tic Eye Exam
• Recommende d Labs
• Other Health Activities

Acquisition of health da ta be yond

care delivere d exclusively thr ough
VHA
Standardized Da ta Elements
EBM guidelines and real time Decision Support at the point of care

EVIDENCE BASED MEDICINE

- XML-format
- Indexed with MeSH (Snomed CT),
ICD-10 -, ATC- and Lab-codes
EBM at the POC
 DS Engine: reports
Interaction of Glitazone
With Insulin, and
Contraindication in heart
failure
 Real time clinical IT
Other Inputs
EBM Guidelines
Patient Safety Measures Decision
Inpatient Quality Measures
Support
Real-time Clinical Status

Effectors

EHR/CPOE CDR Alerts

Prompts/Reminders
Order Sets
Clinical
System Templated care plans
Normalization, Transformation, Patient alerts
Analytic Application

Lab Pharm Rad

 Actual results after clinical IT
implementation
2.10% Inpatient Mortality
2.05%
2.05%
5.00%
Clean Surgery Infection Rate
4.72%
2.00%
4.50%
1.95%
4.00%
Percent

1.90% 3.50%

1.85% 1.83% 3.00%

Percent
2.50%
1.80%
2.00%
1.75%
1.43%
1.50%
1.70%
1.00%
Jul 2003-Sep 2005 Feb 2007-Feb 2008
Time Period 0.50%

0.00%
Jan-Sep 2005 Feb 2007-Feb 2008
Time Period

Courtesy: Midland Memorial, Texas

 United States…
United States EMR Adoption Model SM

Stage Cumulative Capabilities 2015 Q3 2015 Q4

Complete EMR; CCD transactions to share data; Data warehousing; Data

Stage 7 4.1% 4.2%
continuity with ED, ambulatory, OP
Physician documentation (structured templates), full CDSS (variance &
Stage 6 25.4% 27.1%
compliance), full R-PACS
Stage 5 Closed loop medication administration 34.6% 35.9%

Stage 4 CPOE, Clinical Decision Support (clinical protocols) 10.3% 10.1%

Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS
Stage 3 17.3% 16.4%
available outside Radiology
CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE
Stage 2 3.4% 2.6%
capable
Stage 1 Ancillaries - Lab, Rad, Pharmacy - All Installed 1.8% 1.7%

Stage 0 All Three Ancillaries Not Installed 3.1% 2.1%

Data from HIMSS Analytics® Database ©2014 N = 5454 N = 5460

PLEASE NOTE: These graphics are an abbreviated version of the HIMSS Analytics EMR Adoption Model. All
organizations must secure permission to post our model on any public notices and to obtain their score they must
complete the HIMSS Analytics study prior to validation of their score.
Asia Pacific….
Clinical data aggregation and BIG DATA analytics

RESEARCH
Its never that simple…..

PITFALLS
 Automation the wrong way

 To err is human.
 To really screw
things up takes
a computer.

– Anon.
 Poorly maintained decision
support
 Where do guidelines come from?
 Are they consistent with evidence?
 Are they current and valid?
 Who updates them?
 Are their regular audits?
 Would anyone know, if there were a
malfunction?
CPOE as a source of error

 In one tertiary, academic medical center,

using a mature, commercially available
system:
– 22 different types of failures were facilitated by using
the system
– Errors occurred several times a week, if not daily

Koppel, et al., 2005. JAMA, 293(10): 1197-1203.

 Information security

 If not carefully secured,

your wireless network
may leave you exposed...

Courtesy: Colorado Patient Safety

Thank You!

Questions ?