2012 VHA Innovation Research
Jorge A. Ferrer M.D., M.B.A.
Informatician
Department of Veterans Affairs VHA
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Study: Physician Perceptions of Two Electronic Medical Records
(EMRs): VistA (VA) and GE Centricity
Lisa Grabenbauer, University of Nebraska Medical Center (2009)
 Research Objective: Examine physicians’ perspective on the
objective benefits and limitations of current EMR
 Conclusions: Current EMR frustrates physician collection of
data to improve patient care with cumbersome interfaces and
processes
 Recommendations:
 EMR must provide seamless and flexible interfaces
across system boundaries, for data input as well as
data retrieval
 EMR should facilitate patient and team interactions, not
inhibit them
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Study: Karsh, Ben-Tzion, Matthew B. Weinger, Patricia A.
Abbott, and Robert L. Wears. "Health Information Technology:
Fallacies and Sober Realities." Journal of the American Medical
Informatics Association17.6 (2010): 617-23.
• “The ‘We Computerized the paper, so we can go paperless ‘
fallacy”
 Taking the data elements in paper-based healthcare system
and computerizing them unlikely to create an efficient and
effective paperless system
 This surprises and frustrates Health Information Technology
(HIT) designers and administrators
 The reason is designers do not fully understand how the
paper actually supports users’ cognitive needs
 Computer displays are not yet as portable, flexible or welldesigned as paper
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References: Computer-based
documentation
• Aspects of Electronic Health Record Systems. Ed. Harold P. Lehmann,
Patricia A. Abbott, Nancy K. Roderer, Adam Rothschild, Steven Mandell,
Jorge A. Ferrer, Robert E. Miller, and Marion J. Ball. 2nd ed. New York:
Springer Science Business Media, 2006. p310. Print. Health Informatics
Series.
– “Relevant strengths and weaknesses of each note-capture mechanism
vary. Fully structured coded notes, for example, facilitate data
collection for research and real-time decision support but can be
cumbersome to use during patient encounters and may lack the
flexibility and expressivity required for general medical practices.”
– “Handwritten notes, by contrast, are extremely flexible and permit a
high degree of expressivity but may be limited in their legibility and
accessibility for data processing and analysis.”
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References: Computer-based
documentation
• Aspects of Electronic Health Record Systems. Ed. Harold P. Lehmann,
Patricia A. Abbott, Nancy K. Roderer, Adam Rothschild, Steven Mandell,
Jorge A. Ferrer, Robert E. Miller, and Marion J. Ball. 2nd ed. New York:
Springer Science Business Media, 2006. p310. Print. Health Informatics
Series.
– “ Transcribed notes permit facile documentation into a format possibly
useful for machine-based natural language processing for content
extraction and summarization but are expensive to produce and
require a time delay for the transcription process to occur. “
– “It is likely that each note-capture mechanism will find a clinical niche,
with different clinicians and different sites each using the type that
best fits the practice situation of the moment and that will vary during
the course of a day.”
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Innovations in Health IT
Office National Coordinator (ONC) Grantee and
Stakeholder Summit Nov 2011
http://www.tvworldwide.com/events/hhs/111117/def
ault.cfm?id=14109&type=flv&test=0&live=0
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Innovations in Health IT
• “Original thinking is the hardest work there is; it is
also the most rewarding.”
• -Jay Walker
• TEDMED, LLC (chairman and a partner). TEDMED is
an annual innovation summit for healthcare, bringing
together accomplished individuals from many fields
of technology, medicine and business to exchange
ideas and work on difficult medical problems.
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Innovations in Health IT
The 5 “D’s” of big change (Walker)
• Stage 1 Dismissed “you are wasting my time”
• Stage 2 Delayed “not now where busy”
• Stage 3 Disruption “early adopters come in”
• Stage 4 Dominoes “must have solution”
• Stage 5 Dominance “change is status quo”
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AMIA’s Invitational Health Policy Meetings
2006: Toward a National Framework for the Secondary Use
of Health Data
2007: Advancing the Framework: Use of Health Data
2008: Informatics, Evidence-based Care, and Research;
Implications for National Policy
2009: Anticipating and Addressing Unintended
Consequences of HIT and Policy
2010: Future of Health IT Innovation and Informatics
2011: Future State of Clinical Data Capture and
Documentation
2012: Uses of Health Data
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AMIA’s 6thAnnual Policy Meeting
The Future State of Clinical Data Capture and
Documentation
December 6-7, 2011, Washington, D.C.
• AMIA’s 2011 Annual Health Policy Conference considered the
future of clinical data capture, content and documentation
with its challenges and opportunities. Because of the
importance of high quality clinical documentation and data in
supporting patient care, and given current initiatives
encouraging the adoption of electronic health records (EHRs),
it is crucial to understand how documentation and data
capture processes and policies may be affected by “going
electronic.”
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Time spent on documentation
• 21% of time documenting
– Annals Emergency Medicine. 1998;31:87-91
• 21% of time documenting
– Annals Family Medicine. 2005;3(6):488-493
• 1.4 hour/day
– Journal Clinical Oncology. 2002;20(24):4722-4726
• Up from 0.3 hours/day in 1976
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AMIA 2011 meeting assumptions
• Need to transform the way we capture data and document
clinical care
• New technological and technical advances for clinical data
capture and documentation
• New and diverse data sources, health technologies and
devices for data acquisition, collection and reporting,
treatment support, and information dissemination
• Blurring of lines between devices and applications intended
primarily for use by providers, and those intended for patients
• Dynamic environmental factors, trends and issues impacting
clinical data capture and documentation
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AMIA working definitions
Clinical documentation [and data capture] refers to findings,
observations, assessments, and care plans that are recorded
in an individual's health record. It may include data entered
using various methods, such as computer entry, document
scanning, voice dictation, and automated acquisition from
devices.
An individual’s health record is the repository of clinical
information recorded about that person. The record has many
functions.
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AMIA Guiding Principles
Clinical data capture and documentation:
1. Be clinically driven and patient-centric –reflecting an individual’s
longitudinal and lifetime health status
2. Be efficient –enhancing overall provider efficiency, effectiveness and
productivity
3. Be accurate, reliable, valid and complete –enabling high quality care
4. Support multiple uses –including quality and performance measurement
and improvement, population health, policymaking, research, education,
and payment
5. Enable team collaboration and clinical decision making –including the
patient as a member of the team
6. Reflect input from multiple sources –including nuanced medical discourse,
structured items and data captured in other systems and devices
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Usability Present and Future Current Practice and
Future Plans for Usability Experience: “Industry
Perspective” for the Department of Veterans Affairs
SHARPC AMIA Pre-Symposium Dec 2011
W. Paul Nichol, MD
VHA Office of Informatics and Analytics
•
•
•
•
•
CURRENT VistA/CPRS USABILITY CHALLENGES
Electronic representation of paper chart
Dated infrastructure and technological approach
Challenges in rapid change
Clinical practice
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2012 VHA Innovation sandbox
• PURPOSE STATEMENT
– Improve Veterans' health and health care by using
medical innovation and information technology.
Ideas should address quality, safety, efficiency, and
transparency for Veterans.
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2012 VHA Innovation sandbox
• Systems Redesign: Ideas that improve the way our
system works. Examples include: improving best
practices, design and reliability. The outcome of the
idea should address quality and patient safety.
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2012 VHA Innovation sandbox
• Topic: Systems Redesign
• Description: Systems Redesign comprises ideas dealing with overall
workflow improvement and performance monitoring. “Quality is a
system property.” This category focuses on improving how our
health care system functions. Innovations in this category could
have local or national implications and the outcome should address
quality and patient safety.
• Challenge: Is there a system process, policy or architectural change
that could be improved? How can patient flow be improved? How
could new technologies help your systems? Are there better ways
to measure or assess systems? How can processes be made more
reliable? What can be done to make the business of providing
health care more efficient? How can supply chain management be
improved?
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2012 VHA Innovation sandbox
• INNOVATION EVALUATION CRITERIA
• Innovations should address one or more of the
following criteria:
–
–
–
–
Improve patient care (e.g., safety, quality or access)
Improve efficiency (e.g., clinical workflow, cost/benefit)
Impact numerous Veterans, staff or other stakeholders
Address an unmet need rather than incrementally improve
existing methods
– Address team qualifications, approach, and environment
– Support green initiatives
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2012 VHA Innovation references
1.
2.
3.
4.
Aspects of Electronic Health Record Systems. Ed. Harold P. Lehmann,
Patricia A. Abbott, Nancy K. Roderer, Adam Rothschild, Steven Mandell,
Jorge A. Ferrer, Robert E. Miller, and Marion J. Ball. 2nd ed. New York:
Springer Science Business Media, 2006. p310. Print. Health Informatics
Series.
Karsh, Ben-Tzion, Matthew B. Weinger, Patricia A. Abbott, and Robert L.
Wears. "Health Information Technology: Fallacies and Sober
Realities." Journal of the American Medical Informatics Association 17.6
(2010): 617-23.
Hartzband, P., and J. Groopman. "Off the Record — Avoiding the Pitfalls
of Going Electronic." New England Journal of Medicine 358 (2008): 1656658.
AHRQ. Electronic Health Record Usability: Interface Design
Considerations. By D. Armijo, C. McDonnell, and K. Werner. No.. 9(10)0091-2-EF. Rockville, MD: Agency for Healthcare Research and Quality,
October 2009.
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2012 VHA Innovation references
5.
Schiff, G. D., and D. W. Bates. "Can Electronic Clinical Documentation Help
Prevent Diagnostic Errors?" New England Journal of Medicine 362 (2010):
1066-069.
6. Payne, T. "Transition from Paper to Electronic Inpatient Physician
Notes." Journal of the American Medical Informatics Association 17
(2010): 108-11.
7. Simon, S. R., R. Kaushal, P. D. Cleary, C. A. Jenter, L. A. Volk, E. G. Poon, E. J.
Orav, H. G. Lo, D. H. Williams, and D. W. Bates. "Correlates of Electronic
Health Record Adoption in Office Practices: A Statewide Survey." Journal
of the American Medical Informatics Association 14.1 Jan-Feb (2007): 11017
8. Blumenthal, D. "Stimulating the Adoption of Health Information
Technology." New England Journal of Medicine 360 (2009): 1477-1485.
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2012 VHA Innovation references
9. Porter, M.d., Michael E. "What Is Value in Health Care?" New England
Journal of Medicine 363 (2010): 2477-481.
10.Jha, A. K., C. M. DesRoches, and E. G. Campbell, et al. "Use of Electronic
Health Records in U.S. Hospitals." New England Journal of Medicine 360
(2009): 1628-638.
11.Shea, S., and H. Hripcsak. "Accelerating the Use of Electronic Health
Records in Physician Practices." New England Journal of Medicine 362
(2010): 192-95.
12.DesRoches, C. M., E. G. Campbell, and S. R. Sao, et al. "Electronic Health
Records in Ambulatory Care -- a National Survey of Physicians." New
England Journal of Medicine 359 (2008): 50-60.
13.Sequist, T. D., T. Cullen, H. Hays, M. M. Taualii, S. R. Simon, and D. W. Bates.
". Implementation and Use of an Electronic Health Record within the
Indian Health Service." Journal of the American Medical Informatics
Association 14.2 (2007): 191-97.
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