Electronic Health Records vs. Niche
Software that is actually useful for
Family History
Kevin S. Hughes, MD, FACS
Co-Director, Avon Comprehensive Breast Evaluation Center
Massachusetts General Hospital
Bruce Lin
Project Director, Family History for Prenatal Providers
Manager, Public Health Initiatives
March of Dimes
The EHR has tremendous promise as a
means of decreasing workload, decreasing
cost and improving quality of care
The EHR has tremendous promise as a
means of decreasing workload, decreasing
cost and improving quality of care
Reality
•EHRs decrease productivity or are neutral
•EHRs have not been shown to increase quality
•EHRs have not been shown to decrease cost
Consider what Jonathon Bush (AthenaHealth) calls
the ‘Cash for Clunkers’ program. Doctors have to
be paid to install these EHRs
EHR HIT has tremendous promise as a
means of decreasing workload,
decreasing cost and improving quality
of care
Clinical Decision Support
•Apply Algorithms/Guidelines to patient data
•Identify best course of action
•Results displayed as intuitive Visualizations
BRCAPRO Mutation Risk 25%
Suggest Genetic Testing
Facilitates best action as part of workflow
EHR Issues
“Computerization hasn't saved a dime, nor has
it improved administrative efficiency”
• 4,000 hospitals 2003 to 2007
• Computerization
– Weak correlation
• Quality for MI
– No correlation
•
•
•
•
•
Cost savings
Improvements in administrative efficiency
Quality for pneumonia
Quality for heart failure
Overall quality (MI, heart failure, pneumonia)
Himmelstein, The American Journal of Medicine (2010) 123, 40-46
EHR and productivity varies by specialty
100 internists, pediatricians and family practitioners
• 25 to 33 percent drop in MD productivity
• Over time
– Internists slightly above original productivity
– Pediatricians /family practitioners never recovered
Hemant Bhargava, UC Davis Graduate School of Management
Quote from a breast surgeon beginning EHR use
• …our productivity is down 28%
• I am the highest paid transcriptionist in the state
• Each cancer patient chart takes me apprx 1 hour
• For the first time in my career, I turned down an addon patient
Currently: Paper + memory
Patient
completes
paper form
Reviews data
using memory of
guidelines
Documents and
Orders
Orders
Genetic
EHR: Paper + extra work + memory
Patient
completes
paper form
Staff enters
data into the
EHR
Reviews
data using
memory of
guidelines
Documents and
Orders
Same interface for every Specialty
EHR
Small
Database
Meds
Allergies
Mostly
Filing Cabinet
Or
Document Management System
Generic
Interface
Cardiovascular
Pathology
Anesthesia
Mammography
EHR
Generic
IT ≠ EHR
Role of the EHR in Family History
…close to non-existent
While EHRs do poorly for most aspects of medical
care, they are worse relative to family history and
genetics
Health IT
• EHR
– Designed to manage the entire
spectrum of medical care
• Created by large corporations
– E.g., NextGen, Allscripts, eClinicalWorks, Misys,
Centricity, Eclipse, LMR
• ‘Niche’ Software
– Designed for specialty areas
• Homegrown or developed by small
vendors
– E.g., My Family Health Portrait, Jameslink, GREAT,
Progeny, HughesRiskApps
Health IT
• EHR
– Designed to manage the entire spectrum of
medical care
• Created by large corporations
• ‘Niche’ Software
– Designed for specialty areas
• Homegrown or developed by small vendors
Health IT and Clinical Care
• EHR
• ‘Niche’ Software
EHRs are limited to major areas
Notes
Allergies
Path
Reports
Problem
List
Meds
Lab
Adding new features for small markets is expensive
Notes
■
Genetics
Ө Pedigree
Θ Family
Allergies
History
Path
Reports
Risk
■
Problem
List
Meds
Lab
Every EHR must rebuild the same basic
route
EHRs have difficulty improving
• AHIC Core Data Set
– Published 2008
– No EHR Vendor has adopted it
• HL7 Pedigree model for interoperability
– Approved 2006
– No EHR Vendor has adopted it
• Family history upgrade to EHR at my institution
– submitted 2006
– slated for analysis 2009
– Implementation 2013 or later
The American Health Information Community (AHIC) Personalized
Health Care Workgroup
Recommendations to Secretary 2007
… Modular family history tool
… collection of family health history within the
EHR…messaging of … information to a variety
of richer … tools that perform risk analyses…
results of … calculations … returned to the EHR
… for curation
Niche/Modular Software
Innovative approaches to data entry
Patient data entry
Clinician data interface
Innovative approaches to CDS
Risk Algorithms/Guidelines
Visualization appropriate to user
Pedigree drawing
Niche
Software
`
EHR as a repository
Core data set
Interoperable
EHR 2
Testing and iteration possible
EHRs and Niche Software
EHR vendors say:
•Wait for the EHR to do this
•Niche software is not needed
•EHR should not exchange data with Niche Software
Current EHR
Future EHR
Monolithic
Interoperable with multiple ‘Specialty Specific’ systems
Current EHR
Future EHR
Monolithic
Interoperable with multiple ‘Specialty Specific’ systems
Hereditary Risk Identification
CDS
Hereditary Risk Identification
Click open 4 screens
BRCA1+
Hereditary Risk Identification
Typical EHR
HughesRiskApps
Better workflow
Patient enters data
Tablet PC
iPad
Website
Patient
education
al
materials
Clinical Decision
Support
EHR
Reviews Report &
Pedigree
Reviews suggested
management
Clinical Decision
Support
Documents and
Orders
Current EHR
Future EHR
Decrease productivity or neutral
Increase productivity
Mostly document repository
Database
Mostly free text
Structured data
Data entered by staff or provider
Data entered by patient, staff or
provider
Generic interface
Specialty specific interfaces
Rudimentary CDS/Drug-Drug
interactions
Effective CDS for multiple
specialties
View isolated transactions
View consolidated information
about a given problem
Proprietary hidden information
Open access to patient data
Monolithic, barely intraoperable
Interoperable with multiple ‘best
of breed’ systems
Current EHR
Future EHR
Monolithic
Interoperable with multiple ‘Specialty
Specific’ systems
HughesRiskApps
Breast Surgery Module
www.HughesRiskApps.net
Kshughes@Partners.org