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Lessons for Argentina from the Health Information Technology Experience of the United States Presentation Lessons for Argentina from the Health Information Technology Experience of the United States Presentation to the 37 o Congreso Argentino de Pediatria Joseph H Schneider, MD Chief Health Information Officer Indiana University Health AAP Council of Clinical Information Technology and Child Health Informatics Center October 1, 2015 3/15/2018 1

Hola y Gracias 2 Hola y Gracias 2

My First Meal in Mendoza 3 My First Meal in Mendoza 3

Our Objectives – To communicate: • How the United States’ path towards electronic medical Our Objectives – To communicate: • How the United States’ path towards electronic medical records (EMRs) and health information technology (HIT) evolved • Selected benefits and risks of electronic medical records • Lessons for Argentina as you look to making pediatric care electronic • Opportunities for cross-collaboration in development of EMRs and HIT “por un futuro mejor: niños y adolescentes saludables en tiempos de cambio“ 3/15/2018 4

How We Fly/Bank/Buy How We Fly/Bank/Buy

How Pediatric Care Is Recorded How Pediatric Care Is Recorded

What Are the Problems with Paper? 2005 JAMA Study: • Clinical information missing in What Are the Problems with Paper? 2005 JAMA Study: • Clinical information missing in 14% of visits – 44% had an adverse effect on patient care – 59% caused delayed care/additional services – Missing charts three times more prevalent with complex patients • Charts were not available when the office was closed or if urgent care needed • Studies like this helped support the US to implement the Meaningful Use program where $30 billion is being spent

Where is the US in EMR use? • From 2006– 2013, the % of Where is the US in EMR use? • From 2006– 2013, the % of physicians using any EMR system increased from 29% to 78%. • Nearly half use a “basic” EMR, i. e. , with patient history, demographics, problem list, physician notes, medications, allergies, e-prescribing, and laboratory and imaging results. 3/15/2018 8

Where is the US with EMR use? • In a 2012 study, pediatrician EMR Where is the US with EMR use? • In a 2012 study, pediatrician EMR usage was at 79% with 31 % using a “basic” EMR. • But only 14% used advanced EMR tools such as weight -based dosing/tracking immunizations • One-to-two pediatrician practices were less likely to have an EMR • Younger physicians were more likely to have an EMR. 3/15/2018 9

Where is the US in EMR use? AAP and other Pediatric Activity • 2002: Where is the US in EMR use? AAP and other Pediatric Activity • 2002: Council on Clinical Information Technology (COCIT) • 2003: #1 Board resolution for a pediatric friendly EMR • 2004: First electronic transfer of pediatric patient information using AAP-supported Continuity of Care Record • 2005 Partnership for Policy Implementation formed to improve “computability” of AAP guidelines • 2009: Child Health Informatics Center (CHIC) formed to help lead AAP’s HIT efforts • 2013: Model Child Electronic Health Record Format 3/15/2018 10

Where is the US in EMR use? 2009: Meaningful Use Acceleration • From 2004 Where is the US in EMR use? 2009: Meaningful Use Acceleration • From 2004 -2009 a US Office of the National Coordinator of HIT existed, but its biggest accomplishment probably was just a strategic plan. • But in 2009 over $30 billion was committed to Meaningful Use and the development of many supporting structures for HIT such as informatics education, health information exchanges, and more 3/15/2018 11

Where is the US in EMR use? Meaningful Use: goods/bads • Lots of physicians Where is the US in EMR use? Meaningful Use: goods/bads • Lots of physicians and hospitals now have EMRs, yielding some great benefits in legibility and quality • Unfortunately there are over 1, 000 different vendors • New types of errors and problems have arisen • Still limited health information exchange despite EMRs 3/15/2018 12

EMR Benefits and Risks: Things EMRs Currently Do Well • Legibility • In about EMR Benefits and Risks: Things EMRs Currently Do Well • Legibility • In about 80% of cases, improved practice finances • Quality improvements: quick record access, protocols allergy, interaction checking, etc. • Improved staff & physician morale • Reduced turnover • Parents love the technology - Known as “The Docs with the EMR” 3/15/2018 13

EMR Benefits and Risks: Opinions Before Implementation (Pre-MU) Expense of implementation 94% Inability to EMR Benefits and Risks: Opinions Before Implementation (Pre-MU) Expense of implementation 94% Inability to find an EMR that meets needs 80% Physician resistance 77% System downtime 72% Lack of clear return on investment 71% Transience of vendors 70% Increase in physician workload 64% Physicians have inadequate computer skills 60% No improvement in patient care or quality 58%

EMR Benefits and Risks: Opinions Post Implementation (Pre-MU) Improved documentation completeness 94% Improved access EMR Benefits and Risks: Opinions Post Implementation (Pre-MU) Improved documentation completeness 94% Improved access to records 94% Reduced risk of medical errors 86% Improved quality of care 84% Improved communication with specialists 83% Improved office productivity 77% Long-term savings 75% Made documentation easier 65% More confidential and secure 64%

EMR Benefits and Risks: Typical Physician Acceptance (Pre-MU) Are you satisfied with using your EMR Benefits and Risks: Typical Physician Acceptance (Pre-MU) Are you satisfied with using your EMR? 16

EMR Benefits and Risks: New types of errors 3/15/2018 17 EMR Benefits and Risks: New types of errors 3/15/2018 17

EMR Benefits and Risks: Our Goals Have Changed • Pre 2009, legibility, reduced errors EMR Benefits and Risks: Our Goals Have Changed • Pre 2009, legibility, reduced errors and better information access were seen as important • Meaningful Use had very robust goals that have only partly been met 3/15/2018 18

So - What Have We Learned? • EMRs and other technology have strengths/weaknesses; like So - What Have We Learned? • EMRs and other technology have strengths/weaknesses; like everything else, we need to address these • Reducing costs and impact to small practices & hospitals through cloud computing can help with satisfaction/safety • Processes must be redesigned. Standardizing our work nationally and internationally is key for STEEEP care, efficient research and proper new physician training • Physician involvement in system development and implementation is absolutely vital • Relying on political programs for a strategy is dangerous • Patient involvement and data access is a key to success; in fact, a single record for each patient is the ideal 3/15/2018 19

Recommendations - Can Argentina Avoid the US Mistakes? • Each child should have their Recommendations - Can Argentina Avoid the US Mistakes? • Each child should have their own unique standardsbased secure record for their data – EMRs would contribute to the patient’s record after each visit and draw from it for each visit (EMRs can compete on data presentation and the algorithms they provide) – Consider starting a patient registry for birth information (linked with Plan Nacer? ) and add allergies, medications, immunizations and problems. Then add more with time to generate a longitudinal views of patients from data – Patients should have access to the record and be able to comment on it by using cell phones or computers • With support, could SAP develop this (inter)/national registry/patient record system to make it trusted? • This avoids the data exchange problem that the US has 20

Recommendations - Can Argentina Avoid the US Mistakes? • Consider a “SAP approved” stamp Recommendations - Can Argentina Avoid the US Mistakes? • Consider a “SAP approved” stamp for vendors that meet key requirements (such as contributing to a common patient record) – This avoids the government setting requirements, which is a big problem in the US • Consider that SAP (with the AAP? ) could develop cloud Clinical Decision Support that EMRs could access (e. g. , growth charts that would be populated automatically) • Consider having SAP require that vendors use a single secure communication method to replace regular email, that is tied to all EMRs so that patient interactions can be better tracked 21

Recommendations - Can Argentina Avoid the US Mistakes? • Consider asking each patient to Recommendations - Can Argentina Avoid the US Mistakes? • Consider asking each patient to be a research subject so that the database can be use to develop predictive information for patients/populations • Consider supporting cloud EMRs as they are likely to be the least costly, but there are dangers with limited internet access – Less risk for downtime? – Updates processed immediately rather than waiting for an IT person to do them • Consider modifying learner education so that this system is supported by new physicians 22

Recommendations - Can Argentina Avoid the US Mistakes? Redesigning Processes is Critial Extensive physician Recommendations - Can Argentina Avoid the US Mistakes? Redesigning Processes is Critial Extensive physician involvement is critical 23

Standards: Can we work together towards “un futuro mejor…? • Can we work together Standards: Can we work together towards “un futuro mejor…? • Can we work together on international pediatric standards for: – A single repository for children, separated by language – Patient input to EMRs and HIT – Protocols/order sets – Research (should we think of every patient as a research subject? ) – Quality processes and outcomes measures (e. g. , newborn screening and follow-up) – EMR presentation of new data types, e. g. , genetics 3/15/2018 24

Argentine Pediatricans: Is it Time To Take the EMR Plunge? Yes, especially if • Argentine Pediatricans: Is it Time To Take the EMR Plunge? Yes, especially if • you are under 55 • you care about REALLY improving quality of care in Argentina • you want to help develop SAP/Argentina as a leader in technology

Adios, Gracias y Preguntas Joseph H Schneider, MD drjoes 1 tx@gmail. com Indiana University Adios, Gracias y Preguntas Joseph H Schneider, MD drjoes 1 [email protected] com Indiana University Health Indianapolis, Indiana American Academy of Pediatrics Council on Clinical Information Technology (COCIT) Child Health Informatics Center (CHIC) Elk Grove Village, Illinois