i5021 Technology-Enabling Digital Documentation

1. i5021 Technology-Enabling Digital Documentation i5021 Innovation: Technology-Enabling Digital Documentation (TEDD) Jorge A. Ferrer M.D., M.B.A. | Informatician | Veterans Health Administration | Health Informatics-Knowledge Based Systems | E mail: jorge.ferrer@va.gov Adjunct Assistant Professor School of Biomedical Informatics University of Texas Health Science Center at Houston

2. i5021 Technology-Enabling Digital Documentation VHA 2012 VAi2 Employee Innovation • Voted 20 out of 3,841 innovation competition ideas by VA employees • A HITIDE initiative within the VA portfolio • Joint public-private sector collaboration between the VA and Rover Technologies, LLC • The project is sponsored by Dr. Jorge Ferrer from the VHA Office of Health Informatics-Knowledge Base Systems and managed by Dr. Greg Shorr, CMIO at Rover Technologies • Oversight provided by a team of established informaticians and administrators drawn from the VHA, DOD, Federal agencies, academia and industry

3. i5021 Technology-Enabling Digital Documentation VHA 2012 VAi2 Employee Innovation • A HITIDE initiative within the VA portfolio • Health Information Technology Innovation and Development Environments (HITIDE): A Model for Health Information Technology Innovation • HITIDE represents an “active innovation ecosystem that fosters collaboration of federal and private partners health IT-electronic health record innovations”. • http://www.nitrd.gov/nitrdgroups/index.php?title=Health_IT_R%26D_SSG/Health_Information_Technology_Innovation_and_Development_Environments_Subgroup_(HITIDE)#title

4. i5021 Technology-Enabling Digital Documentation Problem Statement The purpose of the innovation is to build a new clinical documentation platform that overcomes the major limitations and drawbacks of the traditional GUI workstation. The primary design objectives are to provide tight integration with any defined workflow, improve usability with a new generation of technical solutions, enable portability of a familiar user experience (UX) across disparate EHR systems, and enhance the patient experience (PX) at the point of service.

5. i5021 Technology-Enabling Digital Documentation • Project Goals and Design Principles • Objective: Fundamentally improve clinical documentation at the point of service • First Principles: • Tell the patient’s story • Fill in knowledge gaps • Minimize the intrusiveness of information technology in the exam room and points of care • Let the workflow process drive the technology – not the other way around

6. Strategy for Minimizing Intrusiveness and Improving Provider-Patient Interaction • Replace the current note-centric UX with a story-centric UX • A story is a set of problem-oriented paragraphs along with some personal information and health maintenance reminders. • The story is iteratively and automatically updated as knowledge gaps are resoled. Information carried forward not copied forward. • The story is shared by the provider and patient • Streamline the documentation process and simplify navigation • Context sensitive, scenario-specific UX that is dynamically created for each patient encounter • Integration of reading and writing • Support for and incorporation of scratch notes • Employ less intrusive platforms and modalities for documentation at the point of service • Digital writing on digital paper and tablet PCs • Real time voice transcription

7. i5021 Technology-Enabling Digital Documentation Veterans Health Administration Strategic Plan FY 2013 – 2018 • VHA Goals and Objectives: Provide Veterans Personalized, Proactive, Patient-Driven Health Care. • a. VA Health Care Delivery • b. Communication • c. Awareness & Understanding • d. Access to Information & Resources • e. Quality & Equity • f. Innovation & Improvement – VHA will drive an improvement culture by advancing innovation trials, emerging health technologies, and experimentation, through exploration of both constructive failures and dynamic successes, adopting practices that improve care while minimizing and managing acceptable risk. • g. Collaboration – VHA will strengthen collaborations within communities, and with organizations such as the Department of Defense, the Department of Health and Human Services, academic affiliates, and other service organizations.

8. PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under Secretary for Health 1.If data is important enough that it is needed to manage the patient and/or the system, then it must be acquired as an integral part of the work process and not through retrospective data collection. –Data should be acquired in real-time, and in concert with the documentation of clinical activities. 2.Solutions must make the work easier and not impose undue burden or re-work. –Technology must facilitate the workflow, but not drive it. 3.Real-time visibility into the system must be available, and it must be transparent across the enterprise. –Manage all patient-health system interactions (e.g. location and times, waits and delays); manage patient staff relationship (e.g. handoffs); manage all tests and procedures in real-time (from scheduling to completion with concurrent documentation)

9. PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under Secretary for Health Continue: 4.To deliver evidence-based care we must have evidence-based management. –Clinical and Administrative processes support 5.To effectively manage the delivery of evidence-based care we must manage complexity –Data>Information>Knowledge>Wisdom Disruptive Innovation

10. i5021 Technology-Enabling Digital Documentation AMIA’s Invitational Health Policy Meetings • 2006: Toward a National Framework for the Secondary Use of Health Data • 2007: Advancing the Framework: Use of Health Data • 2008: Informatics, Evidence-based Care, and Research; Implications for National Policy • 2009: Anticipating and Addressing Unintended Consequences of HIT and Policy • 2010: Future of Health IT Innovation and Informatics • 2011: Future State of Clinical Data Capture and Documentation

11. i5021 Technology-Enabling Digital Documentation AMIA’s 6thAnnual Policy MeetingThe Future State of Clinical Data Capture and DocumentationDecember 6-7, 2011, Washington, D.C. • AMIA’s 2011 Annual Health Policy Conference considered the future of clinical data capture, content and documentation with its challenges and opportunities. Because of the importance of high quality clinical documentation and data in supporting patient care, and given current initiatives encouraging the adoption of electronic health records (EHRs), it is crucial to understand how documentation and data capture processes and policies may be affected by “going electronic.”

12. i5021 Technology-Enabling Digital Documentation AMIA’s 6thAnnual Policy Meeting (AMIA working definitions) • Clinical documentation [and data capture] refers to findings, observations, assessments, and care plans that are recorded in an individual's health record. It may include data entered using various methods, such as computer entry, document scanning, voice dictation, and automated acquisition from devices. • An individual’s health record is the repository of clinical information recorded about that person. The record has many functions.

13. i5021 Technology-Enabling Digital Documentation AMIA’s 6thAnnual Policy Meeting 2011 Meeting Assumptions • Need to transform the way we capture data and document clinical care • New technological and technical advances for clinical data capture and documentation • New and diverse data sources, health technologies and devices for data acquisition, collection and reporting, treatment support, and information dissemination • Blurring of lines between devices and applications intended primarily for use by providers, and those intended for patients • Dynamic environmental factors, trends and issues impacting clinical data capture and documentation

14. i5021 Technology-Enabling Digital Documentation AMIA’s 6thAnnual Policy Meeting AMIA Guiding Principles Clinical data capture and documentation: 1. Be clinically driven and patient-centric –reflecting an individual’s longitudinal and lifetime health status 2. Be efficient –enhancing overall provider efficiency, effectiveness and productivity 3. Be accurate, reliable, valid and complete –enabling high quality care 4. Support multiple uses –including quality and performance measurement and improvement, population health, policymaking, research, education, and payment 5. Enable team collaboration and clinical decision making –including the patient as a member of the team 6. Reflect input from multiple sources –including nuanced medical discourse, structured items and data captured in other systems and devices

15. i5021 Technology-Enabling Digital Documentation Journal of American Medical Informatics Association: The Future State of Clinical Data Capture and Documentation: a report from AMIA’s 2011 Policy Meeting Caitlin M Cusack, George Hripcsak, Meryl Bloomrosen, S Trent Rosenbloom, Charlotte A Weaver, Adam Wright, David K Vawdrey, Jim Walker, Lena Mamykina • Research Agenda Recommendations • DHHS should fund the development of innovative automated documentation tools, including data input methods that accommodate entry by various methods such as dictation with or without voice recognition, digital handwriting, and document scanning with or without optical character recognition.

16. i5021 Technology-Enabling Digital Documentation Journal of American Medical Informatics Association 2013: The wave has finally broken: now what? (Simborg) • Barriers to achieving the promise of improved quality and reduced cost remain, as well as some unintended negative consequences. • Poor usability of user interfaces: Both anecdotal and formal survey data continue to indicate that physician unhappiness with EHRs remains a problem. A HIMSS task force has described ‘usability’ as ‘possibly the most important factor hindering widespread adoption of EMRs’ • Distrust of EHR-produced encounter notes: EHR vendors incorporate a number of tools in their products to speed up the process of recording a clinical encounter. These include problem templates, copy forward, and ‘singleclick’ entry of review of systems and physical examination components.

17. i5021 Technology-Enabling Digital Documentation Cooperative Research and Development Agreement Veterans Health Administration & Rover LLC. • The CRADA is one of the principal mechanisms used by federal labs to engage in collaborative efforts with non-federal partners to achieve goals of technology transfer. • Intended to be a flexible mechanism that can be adapted to a variety of types of collaborative efforts between federal and non-federal organizations and that can be implemented relatively easily within a relatively short time. • VAi2 Innovation Wiki Site • http://sandbox.vacloud.us/groups/5021/