December 3, 2013
Just over a year ago, a patient walked into the office of Tom Yackel, M.D., MPH, M.S. ’02, an OHSU internist, and asked, “Dr. Yackel, I’m due for a colonoscopy. Can you order me one?”
“My jaw about dropped,” said Dr. Yackel. Normally, he’s the one convincing patients they’re due for the procedure, he explained, not the other way around. But because patients can view their medical record through a secure, online patient portal in OHSU’s electronic health record (EHR) system, they’re tracking their health, getting electronic reminders and taking charge. Dr. Yackel, OHSU’s chief health information officer, is thrilled.
Health care reform, in many ways, rests on EHRs and other information systems; without them, you can’t retrieve and analyze information. Yet, will they help achieve the “Triple Aim” of better patient experiences, better coordination of care and lower costs? That verdict will take years.
In the meantime, as national EHR adoption rates climb toward 60 percent (76 percent in Oregon) and incentive programs spur their meaningful use, EHRs are here to stay, and their benefits are slowly but surely coming into view. In this environment, OHSU clinician-scientists are turning the university’s own EHR into a laboratory of sorts that promises to intelligently push this medical device into the future.
Building a power tool
By 2008 or so, OHSU featured an inpatient-ambulatory EHR, an integrated system that was fairly rare at the time. Today, it includes pharmacy and lab modules, alerts and reminders for clinical decision support and patient and referring provider portals. Data are going in. “Now it’s time to get the information out, and that’s where the tool’s real power lies,” said Scott Fields, M.D., R ’89 professor and vice chair of family medicine, and a faculty leader in OHSU’s EHR implementation.
Dr. Fields and his department use the EHR not only for billing and documentation but for analytics. Each month, “balance scorecards” calculate patient satisfaction, quality of care and economic efficiency data for each physician.
The department also generates quarterly reports across populations. An example might be a report showing pneumococcal vaccination rates across time in patients over 65 or for those with chronic diseases such as diabetes, coronary disease or chronic obstructive pulmonary disease. OHSU Family Medicine uses these advanced data to intervene and improve care for individuals and across populations. “We could never have done this without an EHR,” said Dr. Fields. “It’s very cool. When you look at the use of analytics nationwide, we’re just scratching the surface.”
Learning to read
The good news is there are loads of data; the bad news is there are loads of data. Jeffrey Gold, M.D., associate professor of medicine and director of OHSU’s critical care fellow program, loves EHRs but likens them to an enormous “Where’s Waldo?” puzzle. The answer to a patient’s condition is in there somewhere, but it’s often difficult to find.
Dr. Gold is on a mission to better train physicians in their use. “The electronic health record is potentially the most powerful and widely-used medical device today, and it has the most ability to cause harm if used incorrectly,” he said. He’s working to change that.
Last October, his team was awarded a $1 million grant from the federal Agency for Healthcare Research and Quality to develop studies that will shed light on the EHR. So far, the work has led to several simulations, one of which is a sophisticated computer test that clones OHSU’s EHR environment to mimic a realistic ICU case with days of data. Fellows and residents have 10 minutes to review the case and then discover why the patient is medically decompensating.
With 100 tests completed so far, Dr. Gold has a baseline, and now he’s using a sophisticated eye tracker to learn exactly how providers read EHR screens. The next step, he says, is to employ scientific methodologies to identify what kind of EHR training and software design will help reduce medical errors and improve care.
Charting the future
At OHSU, first-year M.D. students begin learning the EHR in week two. They advance from creating a progress note to placing and reviewing orders to – in their third year – using the EHR during a clinical visit while maintaining patient rapport. In the Physician Assistant program, EHRs are a key part of both simulated and clinical learning environments.
“The goal is not so much to master specific technical skills,” said Frances Biagioli, M.D., R ’98 associate professor of family medicine and EHR instructor, “because EHRs are rarely the same from organization to organization, but to teach important concepts about harnessing technology to deliver better care.”
The use of EHRs specifically – and technology in general – is top of mind as the School of Medicine transforms its M.D. curriculum. Paul Gorman, M.D., associate professor of medical informatics and clinical epidemiology, chairs the work group which is investigating how to integrate technology into the curriculum.
Most academic health centers, he and the group found, are grappling with similar issues in a world where technology morphs at lightning speed. “Our job as faculty is to provide students with the adaptive skills to adjust their workflow and practices to fit with new technologies while maintaining the patient care principles that are the foundation of our profession,” observed Dr. Gorman.
The economics of EHRs can’t be ignored. The U.S. market for electronic health records was valued at $17.9 billion in 2011; in 2012, it increased 15 percent to $20.7 billion, according to Kalorama Information. “If academic health centers like us don’t take an active, independent approach in all aspects of the EHR, then there are a lot of corporations really interested in getting into this space and directing it,” said David Dorr, M.D. R ’02, associate professor of medical informatics and clinical epidemiology. “It’s important to have entities like us that independently study the EHR environment and draw their own conclusions.”
Lessons learned from OHSU’s clinical, research and educational work will become public information. They’ll be honed into clinical best practices passed to future providers. They’ll be tested and improved by organizations elsewhere. And in this way, OHSU faculty members are offering solid digital direction in the vast space of bits and bytes.
This article originally appeared in the Fall 2013 edition of Bridges alumni magazine.