EMR, stark relaxation

1. Technology in the office
Carl Dirks, MD, CMIO, Saint Luke’s Health System

2. Vision of technology

3. Vision of technology

4. Dr. Homer Warner
Salt Lake City, Utah 1960’s

6. State of the Union
2004
“By computerizing
health records, we
can avoid dangerous
medical mistakes,
reduce costs, and
improve care. “

7. Drivers of technology
acquisitions
• •
Improve quality Recruit provider staff
• •
Improve safety Increase billing
• •
Report quality Competitive
enhancements
• Improve provider
•
efficiency “it’s the way of the
future”
• Save Money
• “my partner wants it”
• Empower patients

8. • “A repository of electronically maintained
information about an individual's lifetime health
status and health care, stored such that it can
serve the multiple legitimate users of the record.”
• “The current term used to refer to
computerization of health record content and
associated processes.”

9. 2005- EHR plans
No Plans
EHR in use
Currently Implementing
within 2 years

10. Percentage of EMR utilization, by Practice Size
50
General EMR EMR System
40
30
20
10
0
1 2 3-5 6-10 >11
Adapted from Blumenthal and Glaser, NEJM June 14, 2007 356:2527-2534

11. HIMSS - 2003 - EHR
The Electronic Health Record (EHR) is a secure, real-time, point-
of-care, patient-centric information resource for clinicians. The
EHR aids clinicians’ decision-making by providing access to
patient health record information when they need it and
incorporating evidence-based decision support. The EHR
automates and streamlines the clinician’s workflow, ensuring all
clinical information is communicated and ameliorates delays in
response that result in delays or gaps in care. The EHR also
supports the collection of data for uses other than clinical care,
such as billing, quality management, outcomes reporting, and
public health disease surveillance and reporting.

12. Institute of Medicine -
EHR
Core functionalities Other functions
• •
Health Information and Electronic
data communication and
connectivity
• Results management
• Patient support
• Order entry and support
• Administrative support
• Decision support
• Reporting and population
helath management

13. health information and data

14. health information and
data
• clinical information
• medical problems
• medical history
• lab information
• codified versus free text
• CCR/CDA - document - the future??

15. http://www.medcomsoft.com/images/products/components/cpoe_system.jpg
Order entry and support

16. potential unintended
cons
• division of health information
• alert fatigue
• provider revolt

17. Saint Luke’s Care
Saint Luke’s Health System
Physician Orders
Write Down and Read Back for all Verbal Orders
DATE TIME ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Acute Coronary Syndromes – STEMI
1. Admit as inpatient status
2. Level of care: PCU/CVRU ICU
3. Diagnosis – Acute MI
4. Admit to Dr. _________________________________
5. Obtain H & P, discharge summary, consults and ECGs from most recent previous admission
6. SLH only Resident Case Non-resident case
7. Allergies:
8. Telemetry monitoring
9. Labs: (With next lab draw today) Draw HgA1c
Finish ACIP (CK-MB and Troponin at 0 hour, 3 hour, and 6 hour) started in ED
ABG B-type Natriuretic Peptide – BNP CBC
In A.M.
Coag Screen Fasting Lipid Profile Magnesium
Renal Panel T4/TSH Urinalysis
Other________________________________
10. Fingerstick blood glucose AC & HS
11. Diet: clear liquids and/or snacks until sheath removal followed by
Simply Healthy __________ cal ADA Clear liquids NPO
No food after midnight for early morning lab
12. Daily weight
13. Vital signs every 4 hours and prn
14. Consult Endocrinology if patient does not have a history of diabetes & HgA1c greater than 7%
15. Psych consult for any patient who expresses thoughts that they would be better off dead or of hurting themselves
in someway (positive on item #9 of the Depression Screening Protocol)
16. Bedrest
17. Oxygen: continuously monitor oxygen saturation, apply O2 per nasal cannula for SpO2 less than 92%
18. ECG in morning
STAT ECG for angina and notify physician.
19. Echocardiagram – order routine
20. ECG in morning and as needed for angina and notify physician.
21. Offer tobacco cessation education (if patient has used tobacco in the part 12 months)
(Continued)
ALLERGIES / INTOLERANCES Affix Patient Label To ALL Pages
DANGEROUS ABBREVIATIONS
– DO NOT USE!
MS, MSO4, MgSO4, q.d. or QD,
Height ______
q.o.d. or QOD, U or u, IU
Weight ______ ! kg ! lbs gms
Latex Allergy Yes ! No !
Never use zero after decimal point (1.0 mg)
Page 1 of 3
Always use zero before decimal point (0.5 mg)
SYS-1001 (Rev. 08/01/07)
Decision support

18. • Electronic communication and connectivity
• HIPAA compliant messaging
• interfaces
• interchange/exchange of data - rhio??
• Patient support
• disease managemeent
• personal health record
• Administrative support

19. Reporting initiatives
• PQRI - Medicare Physicians quality
reporting intiative Societal Reporting
initiatives
• Other Payors?

20. Certification Commission for
Health care Information
Technology
• The Certification Commission is a recognized
certification body for electronic health
records and their networks, and a private,
nonprofit initiative.
• Our mission is to accelerate the adoption of
health information technology by creating an
efficient, credible and sustainable
certification program.

21. CCHIT.ORG
• Formed 2004
• American Health Information Management Association
(AHIMA)
• Healthcare Information and Management Systems Society
(HIMSS)
• The National Alliance for Health Information Technology
(Alliance)

22. 2005 CCHIT funders
• •
AAFP Sutter Health
• •
AAP United Health
Foundation
• ACP
• WellPoint, Inc.
• California HealthCare
Foundation (CHCF)
• Hospital Corporation
of America
• McKesson

23. society endorsements
• •
AAFP AMIA
• •
AAP Physicians Foundation
for health systems
• excell.
ACP
•
• Physicians’ Foundation
ACEP and AEP (ER)
for health systems
• innovations
MGMA
• AMA

24. Current Stakeholders
• Clinicians and provider organizations who purchase health IT products
• Safety net providers who purchase or receive health IT products
• Vendors who develop, market, install and support health IT products;
• Payers or purchasers who are prepared to offer incentives for health IT
adoption
• Health care consumers
• Quality organizations
• Public health agencies
• Clinical and health-services researchers
• Standards development organizations
• Federal agencies and coordinating bodies representing various Federal agencies
as identified by the National Coordinator.

25. Certification highlights
• •
EHR vendors apply for Certification for 3 year
certification - application periods
fee ($30,000)
• Annual updates of
• Jury observed scripts of criteria
functionality - includes
MD
• attestation of features
submitted

26. CCHIT.ORG- Certification
• Functionality
• Interoperability
• Security

27. Final Ambulatory Functionality Criteria March 16, 2007
2007 Certification of Ambulatory EHRs
AMBULATORY FUNCTIONALITY Provisional Criteria (2007) are highlighted in yellow
2007 Final Criteria - March 16, 2007 Compliance Key:
For 2007 Certification of Ambulatory EHRs P = Previous Criteria
N = New for Year
© 2007 The Certification Commission for Healthcare Information Technology
M = Modified for Year
Original Source or
WG Category and Description Specific Criteria Compliance
line # References*
Certify in May 2007
Roadmap for May
Roadmap for May
Phase I
2009 and beyond
Discussion / Comments
* See reference list
2008
at end of document
1. The system shall provide the ability to display all DC.1.4.3 We assume current and active to mean the
F Manage problem list: Create and
13 P
current problems associated with a patient. same thing.
maintain patient specific problem
lists. 2. The system shall provide the ability to maintain a DC.1.4.3 This means both current
14
history of all problems associated with a patient. and inactive and/or resolved problems.These
may be viewed on separate screens or the
P same screen. Ideally each discrete problem
would be listed once.
3. The system shall provide the ability to maintain the DC.1.4.3 It is a vendor design decision whether to
15
onset date of the problem. require complete date or free text of
P
approximate date.
4. The system shall provide the ability to record the DC.1.4.3
16
chronicity (chronic, acute/self-limiting, etc.) of a P
problem.
5. The system shall provide the ability to record the DC.1.4.3
17
user ID and date of all updates to the problem list. P
6. The system shall provide the ability to associate DC.1.4.3 One should be able to identify all visits for a
18
orders, medications, and notes with one or more particular diagnosis/problem. .
N
problems. Association can be made in structured data or
in non-structured data.
7. The system shall provide the ability to associate
18a
orders, medications and notes with one or more
2009
problems; association to be structured, codified data.
8. The system shall provide the ability to maintain a DC.1.4.3 For example: ICD-9 CM, ICD-10 CM,
19
coded list of problems. SNOMED-CT, DSM-IV. The Functionality
P WG will not specify which code set(s) are to
be employed.
9. The system shall provide the ability to display
20 P
inactive and/or resolved problems.
10. The system shall provide the ability to separately
21a
display active problems from inactive/resolved N
problems.
CCHIT Ambulatory FUNCTIONALITY Criteria 2007 Final 16Mar07 Page 3 of 46

28. Final Security Criteria 2007 Certification of Ambulatory and Inpatient EHRs March 16, 2007
Legend:
Security - 2007 Final Criteria - Mar 16 2007 Provisional Criteria (2007) are highlighted in yellow
Final Secuirty Criteria For 2007 Certification of EHRs P= Previous
© 2007 The Certification Commission for Healthcare Information Technology N= New
M= Modified
Line # Compliance
Roadmap for May 2008
Roadmap for May 2009
Source or References
Certify in May 2007
WG Category and Description Specific Criteria Discussion/Comments
and beyond
* See end of document for references.
When passwords are used, the system shall not transport Canadian: Ontario 5.3.12.a (System Access Management);
S25 P
passwords in plain text. CC SFR: FCS_CKM;
SP800-53: SC-12 CRYPTOGRAPHIC KEY ESTABLISHMENT
AND MANAGEMENT;
HIPAA: 164.312(e)(1)
When passwords are used, the system shall not display CC SFR: FPT_ITC;
S26 P
passwords while being entered. ISO 17799 9.2.3;
HIPAA 164.312(a)(1)
For systems that provide access to PHI through a web CC SFR: AGD_ADM
S27 P
browser interface (i.e. HTML over HTTP) shall include
the capability to encrypt the data communicated over the
network via SSL (HTML over HTTPS). Note: Web browser
interfaces are often used beyond the perimeter of the
protected enterprise network
The system shall support protection of integrity of all CC SFR: FPT_RCV
S28 P
Protected Health Information (PHI) delivered over the
Internet or other known open networks via SHA1 hashing
and an open protocol such as TLS, SSL, IPSec, XML digital
signature, or S/MIME or their successors.
The system shall support ensuring the authenticity of remote CC SFR: FPT_RCV
S29 P
nodes (mutual node authentication) when communicating
Protected Health Information (PHI) over the Internet or other
known open networks using an open protocol (e.g. TLS,
SSL, IPSec, XML sig, S/MIME).
Sec The system, when storing PHI on any physical media FIPS 140-2, CC SFR: FCS_COP, OMB M-06-16 N
S30
intended to be portable/removable (e.g. thumb-drives, CD-
ROM, PDA), shall support use of a standards based
encrypted format using triple-DES (3DES), and the
Advanced Encryption Standard (AES).
Sec Security: Authentication The system shall support two-factor authentication in CC SFR: FIA_UAU; N
S31
alignment with NIST 800-63 Level 3 Authentication. Note: SP800-53: IA-2/AC-19, OMB M-06-16
The standards in this area are still evolving.
Sec Security: Technical Services The system shall support the storage of any Protected FIPS 140-2, CC SFR: FCS_COP, OMB M-06-16, SP800-53: AC- N
S32
Health Information (PHI) data on any associated mobile 19
device(s) such as PDAs, smartphones, etc. in an encrypted
format, using triple-DES (3DES), the Advanced Encryption
Standard (AES), or their successors.
CCHIT Security Criteria 2007 Final 16Mar07 Page 5 of 9

29. KLAS ambulatory EHR
rankings
EpicCare Ambulatory
1
• Industry review EMR
2 TouchWorks EHR
system
• 3 Misys EMR
quality, features
• marketshare 4 GE Centricity EMR
5 NextGen EMR
http://www.healthcareitnews.com/story.cms?id=7697

30. State of the Union
2004
“By computerizing
health records, we
can avoid dangerous
medical mistakes,
reduce costs, and
improve care. “

31. Medicare Modernization
Act-2003
• •
Called on secretary of underwriting could
HHS to promote not be determined
development of based on volume
standards for
•
interoperability for electronic prescribing
electronic prescribing tool must utilize
developed standards
• Allows 3rd parties to
•
underwrite cost of also created medicare
electronic prescribing part D drug program
for clinicians
Federal Register/Vol. 71, No. 152/Tuesday, August 8, 2006/Rules and Regulations
http://www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-1303-F.pdf

32. EHR anti-kickback exception 9/8/2006
• “software necessary and used predominantly to create,
maintain, transmit, or receive elecronic health records.
Software packages may include functions related to patient
administration, for example, scheduling functions, billing, and
clinical support”
• Must include electronic prescribing capability
• Information technology and training services, which would
include, for example, internet connectivity and help desk
support services.
• Electronic health records must be interoperable
• providers must pay at least 15% of cost of solution
• No hardware included, no underwriter financing
Federal Register/Vol. 71, No. 152/Tuesday, August 8, 2006/Rules and Regulations
http://www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-1303-F.pdf

34. Wait….
• Provisions did not affect tax law.
• enurement restrictions still applied to not
for profits….

35. Internal Revenue Service
memorandum
date: 05/11/07
Director, Exempt Organizations, Examinations SE:T:EO:E
to:
Director, Exempt Organizations, Rulings & Agreements SE:T:EO:RA
Director, Exempt Organizations SE:T:EO
From:
!quot;#$%&'%!()*()%
/s/
Hospitals Providing Financial Assistance to Staff Physicians Involving Electronic
subject:
Health Records
The purpose of this memorandum is to provide a directive for handling examination
and exemption application cases involving hospitals that provide physicians who have staff
privileges at those hospitals (“medical staff physicians”) with financial assistance to acquire
and implement software that is used predominantly for creating, maintaining, transmitting,
or receiving electronic health records (“EHRs”) for their patients.
Many hospitals described in section 501(c)(3) of the Internal Revenue Code (“Code”)
plan to establish interoperable EHR systems to improve the effectiveness and efficiency of
their medical care and to reduce medical errors. Some hospitals believe that their medical
staff physicians need a financial incentive to acquire and implement EHR software that
would allow the physicians to connect to the hospitals’ EHR systems. On August 8, 2006,
the U.S. Department of Health and Human Services (“HHS”) issued final regulations (see
42 C.F.R. Section 411.357 and 42 C.F.R. Section 1001.952) (“HHS EHR Regulations”) that
allow hospitals to provide, within specific parameters, EHR software and technical support
services (“Health IT Items and Services”) to their medical staff physicians without violating
the federal anti-kickback law, 42 USC §1320a-7b and physician self-referral law, 42 USC
§1395nn.
We will not treat the benefits a hospital provides to its medical staff physicians as
impermissible private benefit or inurement in violation of section 501(c)(3) of the Code if the
benefits fall within the range of Health IT Items and Services that are permissible under the
HHS EHR Regulations and the hospital operates in the manner described below.
A hospital that is otherwise described in section 501(c)(3) of the Code enters into
Health IT Subsidy agreements with its medical staff physicians for the provision of Health IT
Items and Services at a discount (“Health IT Subsidy Arrangements”). These Health IT
Subsidy Arrangements require both the hospital and the participating physicians to comply
with the HHS EHR Regulations on a continuing basis. The Health IT Subsidy
Arrangements provide that, to the extent permitted by law, the hospital may access all of

36. incremental steps
• transitional state-
• benefits/risks

40. RelayHealth Hosted Service Clinical
interface host View
Payor Partner
RelayHealth
View View
Patient
View
HL7
Primary Care
HL7
SoC
HL7
•Lab Results
•Radiology Studies Physicians with
SoC •Transcription subscribing EMR
•Pathology
•Discharge Summary
•H&P
•Others? SoC

41. • Pharmacy information exchange network-
• enables electronic prescribing transactions
• formulary checking
• patient utilization histories

42. complimentary
Technology

43. complimentary
Technology
• Interface engine

44. complimentary
Technology
• Interface engine
• voice recognition

45. complimentary
Technology
• Interface engine
• voice recognition
• fax server

46. complimentary
Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
backup

47. complimentary
Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
backup
• office software

48. complimentary
Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
backup
• office software
• marketing website

49. complimentary
Technology
• Interface engine • computer
platform - laptop,
• voice recognition tablet, handheld
• fax server
• data archiving/
backup
• office software
• marketing website

50. complimentary
Technology
• Interface engine • computer
platform - laptop,
• voice recognition tablet, handheld
• fax server • PACS
• data archiving/
backup
• office software
• marketing website

54. implementation
prioritites
• •
Improve quality Recruit provider staff
• •
Improve safety Increase billing
• •
Report quality Competitive
enhancements
• Improve provider
•
efficiency assist in research
protocols
• Save Money
• “it’s the way of the
• future”
Empower patients
• “my partner wants it”

55. Success Factors
• practice management commitment
• Provider commitment
• technology access provisions
• Process reevaluation, rather than
reimplementation
• Project selection - right tool, right time

56. Final thought
Archives of Internal Medicine
2007;167 (13):1400-1405
Electronic health record use and the quality of
ambulatory care in the U.S.
• retrospective, cross sectional analysis of visits in
2003 and 2004 national ambulatory medical care
survey
• compared 17 ambulatory outpatient quality
indicators to visits from “paper” practices
• 14/17 indicators - no difference
• 2 better- BZD/depression, routine UA
• 1 worse- statins for hypercholesterolemia

57. Questions?