The EMR as a Catalyst for Quality

December 29, 2008
Tony Yen, MD

MDNG Hospital Medicine, December 2008, Volume 2, Issue 4

The EMR has long promised a brave new world in which clinical information is synthesized, individualized, and seamlessly delivered to the frontline clinician.

The EMR has long promised a brave new world in which clinical information is synthesized, individualized, and seamlessly delivered to the frontline clinician. The reality has fallen short. Even in the hospitalists’ realm, where sophisticated EMRs are common, a gap exists between current medical practice and the EMR’s potential.

Most of us use the EMR in a basic form that electronically delivers clinical information, such as lab results and dictated notes. Although this basic form of the EMR has little impact on medical practice, advanced EMR features like CPOE and clinical decision support have profoundly changed medical practice and workflow. CPOE combined with real-time clinical decision support alerts physicians to evidence-based orders and potential contraindications. These technologies give patient-specific clinical reminders during the medical decisionmaking process. Despite these benefits, frontline physicians have found CPOE to be a time-consuming obstacle to efficient patient care. Is there a way to use advanced EMR abilities, like CPOE, and also improve physician efficiency? The answer lies within the interdependence between technology and clinical workflow.

What’s in store for hospitalists?

Adam Singer, MD, CEO of The Hospitalist Company and 2008 recipient of Modern Physician’s “Physician Entrepreneur of the Year” award, recently released an indepth look at the hospitalist industry. In addition to providing regional updates about hospitalist programs across the United States and touching on quality improvement initiatives, Dr. Singer discusses the increasing prevalence of medical identity theft, its effects on the corruption of medical records, and the dangers to all those involved. Other topics discussed include patient-centered medical homes and e-prescribing initiatives. You can read Dr. Singer’s report, The State of the Hospitalist Industry, Today and Tomorrow, in its entirety at www.hospitalist.com/ assets/004/5847.pdf.

Implementing advanced EMR capabilities requires more than just additional technology. It requires an understanding of how new technology can complement or interfere with clinical workflow. Clinical workflows based on the use of paper charts need to be redesigned to adopt advanced EMR features. For example, clinical workflow redesign must occur when implementing CPOE, because CPOE changes how and where physicians enter medical orders. The adoption of advanced EMR functions presents a unique opportunity to redesign how we practice medicine. Through extracting greater clinical value from the EMR, we have the opportunity to make our clinical practice more efficient, more evidence-based, and safer. The EMR becomes a catalyst for changing clinical practice.

Medication reconciliation

Our EMR catalyzed change within my hospital’s medication reconciliation process. Prior to using the EMR to help with medication reconciliation, the process contained over 40 separate steps. Most of these steps involved reworking prior steps that were either poorly communicated or incomplete. Prior to activating advanced capabilities within the EMR, we redesigned our medication reconciliation process to streamline the existing process and to take advantage of the EMR’s capabilities.

Quality and competition

By configuring the EMR to complement clinical workflow in tandem with redesigning clinical workflow to take advantage of the EMR’s abilities, physicians and nurses more quickly realized clinical value. Physicians are the key to adopting advanced EMR functions, because they directly impact physician workflow. Hospitalists are uniquely positioned to contribute and lead the process redesign involved in adopting more advanced EMR functions in order to provide greater clinical value.

Is your hospital up to CPOE patient safety standards?

The Leapfrog Group can help you determine that with its

CPOE Evaluation tool at https://leapfrog.medstat.com/ cpoe. They’ll provide your hospital with “a set of patient

scenarios, along with a corresponding set of inpatient

medication orders that users enter into their hospital’s

CPOE and related clinical systems.” Those conducting the

test then record the warnings and responses, and report the results back to the Leapfrog website. Potential scenarios and protocols involve drug—drug or drug–diagnosis interactions, drug allergies, therapeutic duplication, and dosage errors. Hospitals that participate in this evaluation process, which can be taken every six months, will receive immediate scoring and feedback.

To Err is Human publicly pushed medical quality onto the national stage. CMS, IHI, the Leapfrog Group, and others have slowly caught up. Now, physicians and hospitals need to demonstrate quality by using evidence-based guidelines and by reporting specific disease measures. CMS began reporting hospitalspecific quality measures in 2003 for CHF, acute MI, and pneumonia. Since then, CMS and other regulatory bodies annually added more quality measures. The increase in quality measures has rapidly become unmanageable. Using multiple paper order sets to implement evidence-based guidelines can interrupt clinical workflow and interfere with direct patient care. The advanced EMR can relieve physicians of this administrative burden by delivering disease-specific protocols, providing evidencebased guidance, and collecting relevant quality measures. When clinical processes are redesigned

Two major factors have pushed hospitals to extract more value from their EMR: quality and competition. HS_CoverStroy_12'08.indd 14 12/9/08 4:49:50 PM hcplive.com/hospital-medicine to take advantage of the strengths of the EMR, physicians can make better clinical decisions and quality of care can be documented during the daily process of patient care. For example, redesigning the medication reconciliation process alone yields better clinical decision making through a more accurate and timely medication list. By redesigning medication reconciliation to also utilize CPOE with real-time clinical decision support, medication errors can be avoided before orders are even sent to the pharmacy.

Hospitals are increasingly in competition with each other, physician-owned facilities, and retail “minute clinics.” They are all competing to lower costs while improving quality and patient satisfaction. Hospitals must use their EMRs as a way to gather this competitive information to target system-wide change and process improvement. Enterprise EMRs used by hospitals are a rich source of clinical and operational data that can be translated into quality and financial performance. With actionable performance measures, hospitals use a variety of process improvement techniques to effect and monitor changes in clinical practice.

Hospitalists’ unique position The evolution of the hospitalist program Last month, David Bowman, MD, wrote a piece for HealthLeaders Media, in which he discussed the keys to running a successful hospitalist program. Some of the keys that Dr. Bowman mentions include aiming for high quality care by using quality measure like length of stay, readmission rates, and core measures, and adopting the best technology and tools possible. This might mean stepping out of a comfort zone and adjusting to new procedures and standards, but in the long run, it will produce benefits in quality of care and will save programs significant amounts of money. To read more about Dr. Bowman’s keys to success, read his article, “Secrets of Hospitalist Practice Success: A Decade of Learning” at http://tinyurl.com/5mzb70.

Hospitalists are uniquely positioned to optimize the EMR. We experience the constraints and benefits of our existing EMRs with every patient every day. We also see how our EMR frustrates in some ways but enhances in others the clinical experience of our medical and surgical colleagues. Through our unique understanding of clinical workflow and institutional knowledge, we can help our hospitals leverage the EMR’s potential as a clinical tool. Optimizing the EMR directly benefits our daily patient care activities, and a more clinically useful EMR also translates into higher quality and more effective care for the whole medical staff. If you are not already involved in growing your EMR’s abilities, you will likely be hearing from your chief medical information officer soon.

Dr. Yen is an internal medicine specialist, the medical director of information technology, and a practicing hospitalist at the Evergreen Hospital Medical Center, Kirkland, WA.