Epic EMR Adoption, Utilization, and Cost

The point of this blog is: Purchasing and installing an EMR and hoping that you’ll realize a positive return-on-investment is not enough. You need to dedicate the time and resources to constantly iterate, refine and improve the utilization of that EMR over time, far beyond its installation and go-live. It’s a race without a finish line so you might as well train, budget and plan for that accordingly-- up front.

At Northwestern, we take great pride in being one of the first fully-institutionalized adopters of an EHR in healthcare. We’ve had an ambulatory EMR (Epic) for 12 years and an acute care EMR (Cerner) for 10. For the past 18-24 months, we’ve been studying not just the adoption of the EMR, but also studying the utilization of the EMR. Drawing upon an analogy to illustrate the point, if a carpenter buys a pneumatic nail gun, I call that “adoption” of a new tool. But if that carpenter is still using the nail gun to manually pound nails as if it were a hammer, has he achieved “utilization” of the tool? If you believe there is added value to an EMR over a paper chart—or even a word processor-- where does that added value reside and are we using it for those purposes? I’ve been slowly polling and collecting data in an attempt to understand EMR “utilization.” I doubt my data collection process would pass Gallup’s scrutiny, but I still believe that it paints an informative picture. Here’s what I have so far…

Qualitative Assessment of Epic EMR Utilization

“Do you personally use the Electronic Medical Record for the following purposes?”

Remote, Internet-based access to the EMR for the benefit of physician convenience and faster patient treatment: 87%

Data-driven reports and analytics which benefit patient care, such as disease management: 34%

Data-driven clinical research: 73%

Data-driven compliance, regulatory, or accreditation reporting: 19%

Referral communications through a clinical In-Basket or automatic letter generation: 94%

If you are a physician or other clinician who uses an EMR and want to add your 2 cents, go ahead and fill out this survey: EMR Utilization.

Quantitative Assessment of Epic EMR Utilization

Based on data from the EMR itself, we run queries in an attempt to objectively measure how the EMR is being utilized in a few key areas of “added value” over a paper chart. To me, those key areas of added value of an EMR reside in the computable data that’s collected in medication orders and management; allergies management and awareness; problem list management and awareness; and family history of disease Below are the questions we asked in the queries of our data. The reporting period for the queries is December 2008 through April 23, 2009.

Medications: What percentage of encounters included a medication order during the reporting period?: 68%

Clearly, not all patient encounters will include a medication order, so we would expect this number to be less than 100%. What we are really trying to find here is the denominator of all Rx orders to better understand utilization. That’s a tougher number to find-- we’re looking at prescription pad utilization as an indicator.

Allergies: What percentage of encounters included a review of patient allergies during the reporting period?: 68%

Ideally, this should be 100%; there is a checkbox in the Epic EMR to indicate “Allergies Reviewed”, but note that the metric seems to be tightly correlated to medication orders, which is the most important issue, i.e., Are physicians reviewing allergies when they prescribe medications? It would seem so.

Problem Lists: What percentage of patients have an entry in their EMR Problem List during the reporting period?: 64%

Again, not all patients will have an entry in their problem list, but common sense tells me that it should be higher than 64%. Therefore, this metric hints that we are underutilizing our Problem List.

Family History: What percentages of patients have an entry in the Family History section of their EMR during the reporting period?: 59%

It’s possible that a patient has no knowledge of family history or nothing worth noting, but common sense tells me that this number should be higher than 59%. This metric suggests that we are underutilizing the Family History section of the EMR.

$$-- Total Cost of Ownership

Finally, to gain some idea of the cost-to-benefit ratio, we measured the total cost of ownership for Epic-- hardware, software, network connectivity, and labor-- Total Cost. The analysis for this TCO took about 3-4 months and the involvement of over 20 people. It was a very thorough analysis. The TCO for the Epic EMR on our campus, including patient registration and scheduling, is $856 per physician per month, or $10,272 per physician year. We have 640 physicians in our physician group, but over 3,000 Epic users on the campus including staff in the Hospital, private physicians, and researchers who benefit from Epic, but do not expressly support it, financially.

In Conclusion

We are working hard to increase the valuable utilization of Epic at Northwestern, while reducing our costs. In addition to our day-to-day Epic support staff, I have a dedicated team of four “Epic Optimization” specialists who are tasked with cycling through each of our 30 Departments to achieve “Epic Optimization.” I can’t imagine that team ever going away. To lower our central support costs while still improving our utilization metrics, we have an active “Epic SuperUser” program consisting of physicians and nurses in the Departments who receive a higher-level of training and system privileges than a typical user; it’s an official, recognized part of their job description.

Remember: An EMR project never finishes. Train, fund, and plan accordingly… don’t short-change the investment!

Amazon.com to Build New EHR

Amazon.com announced today that it will develop a new Electronic Health Record based upon the same user interface experience and underlying information technology that it uses to support its global ecommerce business.

Said Amazon braintrust, Jeff Bezos, “Our experience with user interfaces and high performance computing are ideally suited to help healthcare. We nudge people’s decision making and behavior with the gentle push of data. When you buy a book on Amazon.com, your user interface is different than my user interface when buying the exact same book. Amazon generates the user interface based on the analytics of the broader context of the customer’s profile, purchasing history, geographic location, and other similar customers’ profiles. The parallels in healthcare are numerous and obvious, such as, “Other physicians who treated this type of patient also ordered these other medications” and “Read how other similar patients rated this treatment protocol” and “These are the other physicians in your social network who treated patients like this most often” and “This MRI is in stock and can be schedule immediately” and “This medication is available at your patient’s preferred pharmacy. Here are some other options and costs” and “Add this patient to my Diabetic Registry” and “Add this patient to my Watch List.” In addition to our unique Amazon user interface, we also have a very flexible, open services oriented software architecture that allows us to work easily with our partners and adapt quickly to changes in the market-- and our systems perform—they are fast and never go down. We will also bring this technical skill set to healthcare, which is hampered by stodgy, unreliable systems that are integrated with fragile message-based data interfaces. This foray into healthcare is not about Amazon. It's about our one billion customers and 21,000 employees. ”

The Amazon story is a spoof, though I wish it weren't. :-)

Lots of us have been planting the seeds of change around the certification of EHRs; that is, they should be certified on something more than simply interoperability-- namely usability, patient safety, and an EHR's impact on quality of care, efficiency of care, and cost of care. Future EHRs must blend patient treatment, patient management, and patient economics in the same user interface, and that EHR user interface must be dynamically generated to suit the personal context of the patient, the provider, and the healthcare system at the provider’s and patient’s disposal. It doesn’t do any good to suggest an advanced and expensive lab test in an EHR’s decision support system if the patient can’t afford it or the healthcare setting is in a remote clinic of the Navajo Nation with no lab facility. For future EHRs, it's all about data-driven context and ambient decision support, the stuff that Amazon nails in spades.

Live from HIMSS: Northwestern Buys BCBS of Illinois

Following the model of healthcare systems that have managed to optimize the cost of care with the quality of care—such as Kaiser, Intermountain, and Geisinger—Northwestern Medical announced the purchase of Blue Cross Blue Shield of Illinois today for $3.3B, making Northwestern the only medical center in the US with a fully-integrated delivery system with a University academic mission.

In the press release, Northwestern emphasized that “…the acquisition will enable us to personally balance the economic tension between providers-- who are economically motivated by patient volumes-- and payers --who are economically motivated by disease prevention and health maintenance.” The press release went on to say, “Owning our own insurance company will also allow us to contract directly with employers and patients, thus creating a more direct economic relationship with our patients. Any profits derived from the insurance arm of Northwestern will be funneled directly back into the teaching, research, and care delivery missions of our enterprise.”

All the above is a spoof… prompted by my wandering mind during George Halverson’s keynote address yesterday at HIMSS. He presented simple but compelling data about balancing the economics of care and the quality of care at Kaiser, which reminded me of similar presentations from another great system, Intermountain Healthcare. During Mr. Halverson’s address, I pondered, “Hmmm… wouldn’t it be a powerful healthcare delivery model if you could combine the best elements of Kaiser and Intermountain’s “quality vs. cost” economic incentives with the best elements of Northwestern’s specialty expertise, research, and academic missions?”

Hmmm… :-)

Privacy Protection: 92% vs. 8%

Several days ago, I passed around a survey to gauge people's concerns about protecting their private information. The survey is now closed and you can see the results and comments here: Survey Results. In summary, 92% of respondents were more concerned with “Protection of my personal identity and financial data” vs. 8% with “Protection of my electronic health record data.”

I appreciate everyone's participation. Although certainly not a "Gallup Certified" survey, the breadth of people responding was very wide and, IMO, very representative of our society.

Clearly, we must and will protect both types of information, particularly in healthcare—this is not an “either/or” situation. However, as we spend limited time and money protecting our private information in general, it would seem that we should take these perceptions of public concern in mind. In healthcare, we’ve spent significant resources protecting personal health information as a consequence of HIPAA, and rightly so, but only recently have we focused similar attention on personal identity theft, as required by the Federal Trade Commission’s “Red Flag” rule.

Thanks again to those of you who participated!