EHR Best Practices, Successful Cases

By pjain      Published June 17, 2019, 6:01 a.m. in blog Health   

Key Factors, Trends, Problems

Marketshare

Provider|Large Share%| No.LargeHospitals| Note ----------|----------------------- Epic |58% | 163 Cerner | 27% | 77 Allscripts| - | 16 MEDITECH| |12 | 16% in all acute hosptals CPSI | - | | 9% in all hosptials

  • Here hospital means large hospitals (500+ beds)

High impact of M&A Activity as Concentration in MSAs

Since 2014, 20 percent of acute care hospitals that have switched EHR vendors have done so as a result of M&A activity, and over 50 percent have done so as part of a broader organization decision.

  • Only Epic and Cerner have had net positive changes in market share - taking from others esp. as mergers happen.

Epic has seen the most benefit from this M&A and standardization activity.”

However, mid-size hospitals oriented EHRs like MEDITECH are the most impacted by M&A activity among customers: 16 of its 33 hospital losses in 2018 were the result of market consolidation by large organizations.

Small and Midsized Hospitals - Acute care

  • Small hospitals with less than 100 beds “will continue to have high purchasing energy as customers face consolidation, governmental regulations, and financial pressures

  • MEDITECH’s Expanse web-based solution

  • It has appealed to both the vendor’s own customers and outside ones— small and mid-sized hospitals.
  • Most impacted by M&A activity among customers: 16 of its 33 hospital losses in 2018 were the result of market consolidation by large organizations.

  • Allscripts Sunrise Clinical Manager (SCM) platform

  • Experienced increased losses in both of the last two years. In 2018, 14 hospitals—nine of which came from one large organization—left
  • Allscripts’ Horizon product, which was acquired in 2017 from McKesson, has been “sunsetted,” as three hospital customers of this platform made go-forward decisions last year, with none choosing Allscripts.

  • Athenahealth—which was recently acquired by private equity firm Veritas Capital and hedge fund Elliott Management. It seems to have paused sales and stopped responding to RFPs, though it told press it is still developing its hospital product.

Clinic EHRs, Small Doctor practices

  • Small patient practices use other EHRs and patient portals - basically offering "free installs" and no customization

  • eClinicalWorks

  • Seems to have no new hospital even mid-sized since 2018. Customers who have contracted for the vendor’s inpatient system in previous years are still waiting for that beta product.

    In 2017, the U.S. Department of Justice announced a settlement that held eClinicalWorks, and the company’s founders and executives liable for payment of $155 million to resolve a False Claims Act lawsuit in which the company allegedly violated federal law by misrepresenting the capabilities of its software and for allegedly paying kickbacks to certain customers in exchange for promoting its product.

EHRs are Silo-ed between health care providers

Now EHRs within a system can reveal all patient information WITHIN a given health care provider. However, between systems, there is a HUGE gap.

In fact now when an individual visits a clinic, the nurse spends a lot of time taking down patient information and updating lists of meds.

EHR ARE expensive Scale favor Large Hospital Systems

At a few doctors clinic, it can cast tens of thousands of dollars to implement a basic EHR system, that is why Epic simply doesn't work, and others like eClinicalWorks, etc. discount "setup" for longer term contracts.

KP spent $4b which is a LOT of money, over 9 m in 10yeras it costs only $45 per member/year . Considering that in 2019 KP charges about $5000 per member in premiums (if paid directly by member not employer), this is is a drop in the bucket.

Obama health care reform act states that "meaningful use of technology" by providers nationally would cost $11 billion. Considering that just KP's 9m member cost $4b over 10 years, the national one is likely to cost hundreds of billions of dollars to implement and deploy fully.

EHR are are life-critical - need DevOps and continuity

You have to invest continuously in the infrastructure over its lifetime. People have to recognize that these systems are life-critical once implemented, so you have to invest in the infrastructure to be sure they are always on.

Unproductive doctors - EHR really slow down doctors and increase frustration

Nurses setup room AND IT system when checkin the room

Security- Single Signon keys - tap and 1-second login/context

EHR Analytics are critical

EHRs need a number of analytic systems that surround the core system to help provide care.

EHR need custom Smarts, Data Driven recommendations boost ROI

KP> We are always doing data mining. Our analytic programs go across all systems and monitor for what we call care gaps: "Are there tests you should be having?" "Did you fail to refill your prescription and as a consequence should we be calling to remind you?" We are constantly monitoring you as a patient. .. Many are proprietary to Kaiser Permanente. But we also buy many systems, so the largest part of our job is integration.

EHR are evolving, data-driven, systems

Exporting and Importing data exchange

KP Fasano> If you asked us for your electronic medical record, we would hand you a thumb drive that is encrypted and give you the encryption code. You could then go to your next provider, and it would be able to look at your health record from Kaiser. As long as you provide them the encryption code, they can read it.

Deploying EHRs are tough

  • Space in clinics and hospitals are at a premium.

LCD based EHR systems in office

WOW carts - workstation on wheels.

Kaiser HealthConnect caregivers enter information on a desktop computer; sometimes the computer is on what you call a "WOW cart," a workstation on wheels.

IPad dominate Mobile use in Clinics - on stands common

  • iPads dominate

  • Progressive Providers are embracing mobile phones on the internal side of the organization, too as it has happened already in the patient side.

Mobile based Patient Engagement

On the patient side, most EHRs let you see your medical record, the ability to email your doctor, look at lab results, and other functions on the Web desktop, iPhones and Android devices.

Mobile based Clinic Productivity is an issue - need for Fast Mobile UX

Kaiser in 2019 launched a project called Health360 that is focused on embracing new mobile technology across their entire internal health care system. For some people, it may be relevant to put it on a stand and have a keyboard. Others will carry it with them and take full benefit of its mobile capabilities.

## Resources - Epic, Cerner Continue to Dominate U.S. Hospital EHR Market, KLAS Finds | Healthcare Innovation

EHR Specific Benefits and Use Cases

Avoid duplicate and Clashing Medical prescriptions

  • Opiod crisis Lesson: Lack of EHR-data sharing problem as patients

  • Initially, for many years, patients could get take multiple doctors to write medical prescriptions and get them from pharmacies, as doctors had no way to check patient's existing prescriptions.

Starting with California, a central addictive and dangerous prescriptions registry was formed which doctors ware required by law to check before prescribing such meds. This helped stem the abuses of the opiod system.

Save 15%+ health care costs on duplicate diagnostics

  • Often doctors on CYA order repeat tests - but often it is pointless to repeat the same test in 6-12 weeks as they don't change even with drug changes.Just having an electronic health record that is connected with all the systems that have to do with delivery of care to a patient means you don't have patients taking duplicate tests. In the United States, I believe the cost of duplicate testing is about 15 to 17 percent of the total health care spend. We don't have that cost.

EHR History

1907 Mayo Clinic starts medical Paper records dominate 100+years

Called the first great breakthrough in medical IT the paper medical record where all data papers, prescriptions were dropped into a paper folder and stored in a file cabinet.

This improved on the previous "accounting-ledger-like" information on patients was kept in a ledger that recorded all of a day's patient visits, one after the other. Different departments kept separate ledgers, making it extremely difficult to track down patient information in a timely manner.

In 2009, only 9 percent of America's hospitals were using even a basic form of electronic health records.

Kaiser Past - Pneumatic-pipe Medical Record systems lasted for decades

Kaiser Permanente is a health care giant with 9 million members, mainly on the West Coast especially California.

It has always been a leader in leveraging health records

In the past they were only on paper and restricted to one site eg Santa Clara hospital and clinics. However within one physical site, for decades pneumatic tubes would rush folded medical record files from central department to the individual clinic or hospital department.

Kaiser's HealthConnect $4b Epic custom-integrations payoff

Kaiser wrote off an earlier $400 m system in 2004 developed with IBM. Lessons included:- a. It like the earlier file-pneumatic pipe system was designed for a single region with the intention of expanding it later. b. The partner IBM had no healthcare expertise and starting from ZERO as compared to later Epic which had decades of battle-tested experience. c. Doctors had to cope with decreased productivity d. There were lots of frustrating system outages which can become life-threatening.

Kaiser's EHR systems become fully operational in 2010 in collaboration with Epic and since then it invested in KP HealthConnect, an electronic health records system that stretches across every department and every Kaiser patient.

While $4b is a LOT of money, over 9 m in 10yeras it costs only $45 per member/year . Considering that in 2019 KP charges about $5000 per member in premiums (if paid directly by member not employer), this is is a drop in the bucket.

Now KP has every piece of information about that patient: health history, diagnosis by other providers, lab results, and prescriptions available at fingertips. 1. The primary care physician has all the information about the patient 2. Specialists have all the information about the patient, 3. Anyone they encounter in any of our hospitals has it as well. 4. All diagnostics and labs, Dicom images and X-rays are stored digitally and are there. 5. All information is also available if a patient goes to the ER.

Resources

"Transforming Health Care: The Financial Impact of Technology, Electronic Tools, and Data Mining," written by Philip Fasano, CIO of Kaiser Permanente,

Kaiser $4b Epic investment


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