Early benefits and impacts of Electronic Patient Record implementation: Findings from the UK. Presented by Steven Shaha, Center for Policy & Public Administration, UK, at HINZ 2014, 11 November 2014, 12pm, Marlborough Room 3

1. Early benefits and impacts
of EPR implementation:
Immediate impact and ROI Findings
from the UK
Professor Steven H. Shaha, PhD, DBA

2. Prof. Steven H. Shaha, PhD, DBAProfessor, Center for Public Policy & AdministrationPrincipal Outcomes Consultant, AllscriptsFormer Director of Research, KLAS
100+ peer-reviewed publications, 200+ peer-reviewed presentations, 2 books
Advisory and consulting work for 11 governments on four continents
Professor or Lectured or at 14 universities and graduate schools
e.g. UCLA, Harvard, Cambridge (UK), King’s College, London University, South Manchester, Yale, Princeton, Columbia, Cornell, Zayed Univ(UAE)
Advisory and consulting to 50+ non-healthcare organisations, including
Disney, Ritz-Carlton, Coca-Cola, New Line Cinema, IBM, AT&T,
Time Warner, Johnson & Johnson, Marriott, 3 Depts. of Defense,
and Pharma: Sanofi, Aventis, Novartis
Education:
PhD, Research Methods & Applied Statistics
DBA, Business Administration (PhD)
MA, MEd, BS
Disclosures & Bio

4. Sample of Peer-reviewed Journals
•Advance for Health Information Executives
•Advances in Patient Safety
•Agency for Healthcare Res & Qual(AHRQJournal)
•American Journal of Ob & Gynecology
•American Journal of Sports Medicine
•Applied Clinical Informatics
•Archives of Otolaryngology, Head &Neck Surg
•Breast Cancer Research and Treatment
•British Medical Journal of Quality & Safety
•Epidemiology and Infection
•Health Management Technology
•Healthcare Financial Management
•Healthcare Technology Management
•Intl. Journal of Medical Informatics
•Intl. Journal of Pediatric Otorhinolaryngology
•Intl. Journal for Quality in Health Care
•Journal of Arthroscopic and Related Surgery
•Journal of Clinical Ultrasound
•Journal of Emergency Nursing
•Journal of Mat, Fetal & Neonatology Med
•Journal of Neurosurgery
•Journal of Obstetrics and Gynecology
•Journal of Orthopedic Trauma
•Journal of Pediatric Emergency Care
•Journal of Perinatal Medicine
•Journal of Perinatology
•Journal of Shoulder and Elbow Surgery
•Journal of the Am Acadof PedOphth& Strab
•Journal of Ultrasound in Medicine
•Journal of Ultrasound in Ob & Gynecology
•Laryngoscope
•Nurse Executive Watch
•Nurse Leader
•Nursing Economics
•Pediatric Critical Care Medicine
•Pediatric Emergency Care
•Pediatrics
•RN Magazine
•Spine
•Intl. Journal of Pediatric Otorhinolaryngology
•The Journal of Bone & Joint Surgery
•Ultrasound in Obstetrics & Gynecology

5. The Dynamics in HealthcarePressure on every aspect of performance
“Variable demand with fixed capacity & poor patient flow.”
“Safety, quality and
value-based delivery.”
“Do more with less.”

6. Early Outcomes from UK
6

7. 2.50
3.00
3.50
4.00
4.50
5.00
5.50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Days
Elective LOS Trust-wide
3-Month Moving Average
Mean Pre vs Post June 2013
Elective LOS (Trust)
Lengths of Stay Trust-wide
Shaha SH, Neve M, Waktare J. (2014). Early Impact and ROI for EMR/EPR Implementation: Results from the United Kingdom. HIC 2014 –
Health Informatics Society of Australia (HISA), Melbourne, August 2014. Don Walker Award.
Elective LOS (Trust)
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
4.38 3.93 -0.45 10.3% 0.000
NOTE: Conservative estimated cases was 500 for 12 months
Impact of
pre-implementation
preparations and planning
Estimated impact: £10.1 million
36 Mo
avg.

8. Lengths of Stay Trust-wide
Impact of planned delay
in implementation
Current average
Shaha SH, Neve M, Waktare J. (2014). Early Impact and ROI for EMR/EPR Implementation: Results from the United Kingdom. HIC 2014 –
Health Informatics Society of Australia (HISA), Melbourne, August 2014. Don Walker Award.
Non-Elective LOS (Trust)
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
5.61 5.42 -0.19 3.4% 0.000
NOTE: Conservative estimated cases was 500 for 12 months
Estimated impact: £7.2 million

9. 0.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0.16
0.18
0.20
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Days
Pre-Op LOS - Elective
Mean Pre vs Post June 2013
Pre Op LOS (Elective) TRUST
Pre-Op LOS
Pre Op LOS (Elective) TRUST
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
0.13 0.08 -0.05 38.3% 0.000
From 3.03 hrs to 1.87 hrs
Impact of
pre-implementation
preparations and planning
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Month
Current average

10. Pre-Op LOS
0.50
0.70
0.90
1.10
1.30
1.50
1.70
1.90
2.10
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Days
Pre-Op LOS - Non-Elective
Mean Pre vs Post June 2013
Pre Op LOS (Non Elective)
Pre Op LOS (Non Elective)
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
1.84 1.53 -0.32 17.1% 0.000
Impact of
planned delay in
implementation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Month
7.68 fewer hours
Current average

11. Did not Attend Rates
7
8
9
10
11
12
Patients
New Outpatient Did-not-Attend Rate
Mean Pre vs Post June 2013
Outpatient DNA Rate New Appts (Trust)
Outpatient DNA Rate New Appts (Trust)
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
10.53 9.44 -1.09 10.3% 0.000
Impact of
pre-implementation
preparations and planning
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Month

12. Did not Attend Rates
6
7
8
9
10
11
12
13
14
15
Axis Title
Follow-up Outpatient Did-not-Attend Rate
Mean Pre vs Post June 2013
Outpatient DNA Rate Follow Up Appts
(Trust)
Outpatient DNA Rate Follow Up Appts (Trust)
Pre Mean
Post
Mean
Net
Change
Pct Change
(+=improved) p-Value
11.56 9.25 -2.31 20.0% 0.000
Impact of
pre-implementation
preparations and planning
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Month

13. Pre Post
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10
Reduced Alert Fatigue and Need …

14. 1 2 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Month
Pre Post
Improved Patient Care and Vigilance …

15. 0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
1 2 3 4 5 6
Week
VTE Assessment on Admission
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
1 2 3 4 5 6
Week
VTE Re-assessment within 24 hrs
Pre Post Pre Post
Improved Patient Management &
Medication Usage …

16. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sep
Oct
Nov
Dec
Jan
Percent receiving Appropriate Anticoag
1 2 3 4 5
Month
Pre
Post
Improved Patient Management & Medication Usage …

17. Beware of Appearances …
17
Completely EMR/EPR replicable?
Not Likely …

18. Average EMR Satisfaction
Average EMR Satisfaction
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013
Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.

19. Average EMR Satisfaction
Average EMR Satisfaction
KLAS Survey Items showing
Significant Differences (p<0.05):
• Overall Satisfaction
• Ease of Use
• Supports Integration Goals
• Product Works as Promoted
• Quality of Implementation
• Money’s Worth
• Likelihood to Recommend
• Implementation on Time
• Delivery of New Technology
• Overall Product Quality
• Product Response Time
• Quality of Training
• Proactive Service
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013
Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.

20. Average EMR Satisfaction
Average EMR Satisfaction
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013 Proceedings, Health Information Society of Australia,
Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.
Sample sentiments from IT Professionals:
• The prescriptive implementation was very effective – no arguments with users
• Clinicians adoption was assured – it’s not an option – it was mandated
• Order sets were finally reduced to where we knew they should be
• The vendor/supplier does not abide neither discontent nor dissension
• The IT workforce is prescribed and more than adequately scaled
Sample sentiments from Clinicians:
• The limited number of order sets allowed was strictly (restrictively) enforced
• We gave up many we had worked through – they prescribed the limited #
• Suggestions for improved adaptability for my practice were not options
• I cannot access my data beyond pre-programmed screens or reports
• I still need my own database for research purposes
• Innovation and integration are limited – we’re back to one-off separate systems
• Any comments regarding “something better” became intolerable
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013
Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.

21. 21
A
• Model A
• Less with Adaptability & Customizability
• Implement & Adjust
• Applications adapt
Average EMR Satisfaction
Average EMR Satisfaction
 Schism Model
 More Prescriptive … versus Adaptability & Customizability
 Implement & Comply
 Users adapt
Schism no mystery
Who wins and
Who loses?
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013
Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.
The Golden Rule

22. 22
•Adaptive Model
•Less Prescriptive with Adaptability & Customizability
•Implement & Adjust
•Applications adapt
Reasons for Variability:
•Internal priorities
•Application updates
Everyone wins together
Y-Axis is expanded here to enable better visibility. Actual data were LESS broad from highs to lows
Shaha SH(2013). Comparative EPR Usability form the Clinician Perspective:What works and what doesn’t for impacting care.Digital Health Service Delivery –The Future Is Now.HIC 2013 Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH(2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH(2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf& Exh, Birmingham, England, April 2013.

23. Lessons Learnt: •The EMR is not “electronified paper”
• Computers that Compute
• Programmability
• Clinical Intelligence
•Adaptability and Interoperability
• Rigidity vs. Openness
•Local Innovation then Broader
Standardization
• “What work here with our needs and capabilities”
• Try, refine, prove … then standardize … then innovate
•Access to Clinical Data
•Community Connectivity
•Outcomes-driven
• Clinical
• Efficiency
• Cash Releasing and Cost Reducing
• Clinician Satisfaction

24. Levels of Information: Needs and Perspectives

25. Signal to Noise Ratio
25
Meaningful notifications requested
versus alert fatigue …