Life After “Go-Live”:
True stories from five
years of EMR use
Eric Rose, MD
Associate Director for Clinical Informatics, Information Systems
Department, University of Washington Physicians Network
Clinical Assistant Professor, Department of Family Medicine and
Division of Biomedical and Health Informatics, University of
Washington
http://faculty.washington.edu/momus/infodoc.htm
May 13, 2002
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May 13, 2002
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Who are YOU?
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How many have used EMR’s?
How many are considering EMR
implementation?
Practice size
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Summary
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Brief overview of EMR’s and
UWPN
Description of some challenges
faced in EMR implementation and
our approaches to these
Suggestions for your own transition
planning and implementation
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EMR overview
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Proposed as "The standard for
medical and all other records
related to patient care"—IOM 1997
Universal adoption urged in “The
next 5-10 years”—NCQA 1999
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EMR overview-Basic
Functions
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Documentation of care
Order entry
Results notification & review
Inter-office and intra-office
communication
Time management tools
Task management tools
Aggregate reporting for population
management
Integration with practice management
software
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May 13, 2002
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UWPN Overview
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8 primary care clinics, 76 providers (FP,
Peds, IM, PA/NP, MH)
PLUS an two other multispecialty
outpatient facilities with total of about 60
providers
Started from scratch in 1997 on
EpicCare
PC workstations in all providers' offices,
nurses' stations, & exam rooms
What I do
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EMR Challenges
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Configuration is a BIG job
Requires rethinking of clinical
workflows to take advantages of
the capabilities of the EMR
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EMR Challenges
Payoff is more than adequate:
The EMR is easy to use
64%
The EMR is worth the time
and effort to use
89%
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EMR Challenges
“Although I'm spending more time at
charting duties than in past
practices, I am also accomplishing
a lot more than in the past. I have
never before had charts with such
complete information.…It makes a
doctor do a better job.”
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EMR Challenges
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Documentation of care
Handling flow of paper documents
from outside the practice
Coding tasks
Clinical alerts & reminders
“Too good” information
management
Asynchronous communication
issues
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Documentation of Care
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Typing is too slow
Voice recognition "not there yet"
Menu-driven templates-Limited
applicability
Proliferation of templates
Modular keyboard macros helpful
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(Paper) Documents from
Outside the EMR
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Documents related to past care
(old medical records)
“Working through outside records
and deciding what to write a
summary on and what to scan and
what to shred is a pain. I'd rather
take a quick look at them, then
throw the whole thing into the back
of the chart, and look at it closer
when I need to.”
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(Paper) Documents from
Outside the EMR
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Documents related to ongoing care
Very time-intensive
 Requires personnel with enough
training to know "where" to enter
the scanned image in the EMR
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Coding Tasks
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EMR’s are designed for coding by
provider, not billing personnel
Systems in greatest use, ICD-9CM and CPT, often illogical &
nonintuitive (asthma example)
The “right code” can be devilishly
hard to find
Partial solutions = code selection
tools (preferred subsets,
synonyms)
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Clinical Alerts & Reminders
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At best, still interrupt the process of care
"Pop-up fatigue“ even for appropriate alerts
False-positives waste time and reduce providers’
overall responsiveness to alerts
 Patient has received the intervention but the
EMR can’t “see” it (done outside our system,
not recorded appropriately, etc.)
 Patient declines an intervention
 Patient has left the practice
 The intervention is not appropriate for the
given patient
Still, we've implemented many good alerts &
reminders
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“So Good it’s Bad” Information
Management
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“Results Overdue” messages
Order cosigning
Clinical alerts, esp. trivial ones
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Asynchronous
Communication Issues
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Usually increases efficiency
because don’t have to interrupt
one another
However, repeated back-and-forth
iterations are frequent
In some cases, face-to-face verbal
communication is more efficient
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EMR Successes
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Better access to information
Population-level disease
management and health promotion
Clinical QI
Clinicoadministrative QI
Billing QI
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Better access to
information
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Availability of the patient record
Easier retrieval of information for
clinical care
Easier access by non-provider
personnel outside the clinic
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Population-level disease
management and health promotion
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Disease-management programs
Automated mailings re: healthpromotion services
Pharmaceutical recalls and safety
alerts
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Clinical Quality
Improvement
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Clinical alerts & reminders
Default prescription parameters
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Clinico-administrative
Quality Improvement
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Referral orders—Set up to reflect
organization of specialty services @ UW
Integration of patient-ed materials with
EMR
Tracking deferred immunizations
Flexible routing of results & messages
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Billing Quality
Improvement
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Immunizations
Med injections
Form completion
Wart/Skin tag destruction
etc.
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Pending projects
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Patient access to EMR
Formulary database integration
Statewide immunization registry
integration
Direct transmission of prescriptions
to pharmacies
Integration of complex guidelines
Clinical trial eligibility alerts
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Tips for success-Vendor
Selection
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Vendor stability
Customer service feedback
Adaptability to all settings where
you'll use it
Scalability
Interoperability with other systems
you are or will be using
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Tips for SuccessImplementation
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Put a lot of resources into the project up-front!
Involve all constituencies
Clinical personnel with "ownership“
Listen, respond, be fair, BUT hold the line with prima donnas
Formalized, mandatory training of users
Responsive user support
Pay attention to workflow issues
Be conservative vis-a-vis configuration issues that imply a
clinical standard of care
Careful documentation
Unambiguous delineation of roles & responsibilities
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Obligatory Weighty Quotation
“Until EMR use becomes the norm for all
practitioners, we will continue to lack the tools
needed to manage the quality and costs of health
care, the scientific basis for health care will
continue to be undermined, and the dramatic
transformation of healthcare so urgently required
will be impeded.”
Don Detmer, MD (Chair--IOM Committee on Improving the
Patient Record) The Computer-Based Record: An Essential
Technology for Health Care 1997 National Academy Press,
Washington DC
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Other Challenges
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No perfect systems yet though progress is rapid
Cost can be a barrier (though maybe less than is
commonly thought)
Interfacing with other systems (lab, scheduling,
billing) is difficult & expensive
Communication between EMR systems is a
LONG way off
Security issues are uncertain
Regulatory barriers (electronic signatures,
prescription requirements varying by state)
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Sources for more
information
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FP Net http://www.aafp.org/fpnet/
Family Practice Management
http://www.aafp.org/fpm/
KLAShttp://www.healthcomputing.com/kl
as/
"Medical Software Reviews"
newsletter
http://www.crihealthcarepubs.com
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References
Priebe, C. and Rose, E. Workflow
Automation with Electronic Medical
Records. In Norris, T.E.
Informatics in Primary Care New
York: Springer, 2002
Ahmad, A. et al. Key Attributes of a
Successful Physician Order Entry
System Implementation in a Multihospital Environment. JAMIA 9
(1): 16-24, 2002 Jan/Feb.
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