Using the Electronic Health Recordto Encourage Evidence-Based Practice

Jonathan S. Einbinder, MD, MPH

Partners HealthCare

(jseinbinder@partners.org)

August 22, 2006

Outline

Meeting information needs – the challenge

Potential of electronic health record (and cautions)

Partners HealthCare Signature Initiative• Smart Forms• Registries

24 doctors and students observed

• 5 clinical questions per patient

• 74% concerned patient care

--Osheroff 1991

Library or

Journal

Synthesis

Medical Record

Patient care information needs in a teaching hospital

Usefulness of medical information

Usefulness = relevance x validity

work to access

--Shaughnessy, Slawson, Bennett 1994

The role of technology (the $64 question)

How can informatics applications:

• identify information needs?

• provide useful information?

• change clinician behavior?

• change patient behavior?

A good place to start is basic management of information to help us do things that we know we should do.

Make sure that patients reliably receive interventions known to be beneficial, leading to improved outcomes.

Getting past 55% performance…

-- EA McGlynn et al. NEJM 2003;348:2635-2645

Established patient care strategies are not used

Random sample of adults in 12 metro areas

Survey and medical records review

439 indicators of quality of care for 30 acute and chronic conditions, as well as preventive care

Key finding: Participants received 54.9% of recommended care

-- EA McGlynn et al. NEJM 2003;348:2635-2645

Impediments to using current best evidence in clinical practice

When to look for new evidence

Where to locate relevant information

How to synthesize it to determine optimal approach

--Haynes et al., JAMIA 1995

Technology (electronic health record) can facilitate effective use of information

Diabetes Population Management

Intervention: • “Novel” population management software (registry)• NP used weekly and emailed suggestions to PCPs.

Results: More testing (A1C and LDL) at intervention clinic. No significant effect for med prescription, LDL and A1C levels.

Grant et al. Diabetes Care 2004;27(10):2299-2305

But, consider the following examples:

OnCall: Population Management for Diabetes

OnCall: Population Management for Diabetes

Intervention: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. Results: The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients versus 22% for controls).

Tierney et al. J Gen Intern Med. 2003;18(12):1060-1.

Computerized reminders for CHF/CAD

Computerized reminders for diabetes and CAD

Intervention: Computerized reminders.

Results: Diabetes reminders resulted in the recommended action in 19% of patients in the intervention group versus 14% of patients in the control group. Annual cholesterol testing HR 1.41, 95% CI 1.15–1.72• ACE inhibitors HR 1.42, 95% CI 0.94–2.14• Statin use – NS• Annual eye exam - NS

Sequist et al. J Am Med Inform Assoc. 2005;12:431–437.

LMR Summary with diabetes reminders

Problem: Proven effective medical interventions are not uniformly applied across health care settings.

Goal: Set standards, improve clinical performance, and achieve national leadership levels of performance reliably across the system.

• Acute Myocardial Infarction (AMI)• Congestive Heart Failure (CHF)• Diabetes• Pneumonia • Smoking cessation

Partners Signature Initiative III Goals and Scope

EMR Framework

Adoption

Get an EMRand use it

Adoption

Get an EMRand use it

Effective Use

Use key EMRfeatures fully

Effective Use

Use key EMRfeatures fully

Smart Use

Leverage EMR

decision support

Smart Use

Leverage EMR

decision support

Diabetes Decision Support Team

Goal: Increase the number of providers using and patients with diabetes being managed with standard evidence-based decision support.

How:• Develop and deploy an integrated suite of information

system tools to assist providers in caring for their diabetic patients. Specifically, this suite will include the Diabetes Smart Form, the Diabetes Registry, and the Diabetes Population Manager.

What are Smart Forms?

Composite application for clinicians, combining documentation, orders, decision support• Use by clinician during an office visit• Support efficient workflow with decision support

Built upon a foundation of clinical applications and services• Data review• Documentation• Actionable decision support and orders

Decision Support: Highlights

Actionable decision support and orders

Smart Form origins

AHRQ Smart Forms and Quality Dashboards grant• 3 year, $1.2M project to evaluate Smart Forms for acute

respiratory infection (ARI) and coronary artery disease (CD) in a randomized trial

Signature Initiative 3• Potential of Smart Forms to promote adherence to evidence-

based guidelines for diabetes. Smart Form for diabetes will be evaluated in randomized trial, along with ARI and CAD.

Smart Forms: Clinical and Quality Opportunity

Address a critical obstacle to effective use of the EMR: integration of documentation and actionable decision-support in a streamlined workflow

Positively impact clinical processes and outcomes

Positively impact attainment of performance targets in reimbursement contracts

Provide mechanism to help achieve goals and objectives for patient safety, disease management, and trend management (in ambulatory care settings)

Knowledge Management: Current

Clinical Contentand

Guidelines

FunctionalKnowledge

Specification

For ARI, CAD, DM: Iterative, painstaking, manual process involving clinical sponsors, developers, analysts – shepherded by KM.

• Able to build first Smart Forms• Needs, issues became apparent• Knowledge Specification approach defined.

TechnicalKnowledge

Specification

CodesRulesTemplatesLogic

Knowledge Management: Future

Over next year, infrastructure and processes will evolve: Tools•Concept Dictionary•Order Catalogue•Template Editors•Rule Editor

Processes•Guideline approval•Functional knowledge spec.•Technical knowledge spec.•Maintenance and updating

Clinical Contentand

Guidelines

FunctionalKnowledge

Specification

TechnicalKnowledge

Specification

CodesRulesTemplatesLogic