1	Primary Care Informatics Research at Partners Healthcare Blackford Middleton, MD, MPH, MSc, FACP, FACMI, FHIMSS Director, Clinical Informatics R&D, Partners Healthcare Assistant Professor of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA AMIA PCIWG Workshop Day, November 2003
2	Overview Motivation at Partners Healthcare Innovation at Scale Current Research Processes Sampling of Current Research & Development Projects
3	The US HealthCare Industry Carefully Watches Itself Crash…
4	US Healthcare Cost Challenges US Healthcare expenditures are $1.4T in 2002, or 14% of GDP Public expenditure on healthcare now 43% of total (up 10% in past decade) Return of double digit healthcare insurance premium increases (Up 11% in 2001) Employer healthcare benefit costs expected to rise 15% on average in 2003 Prescription expenses projected to increase 12% in 2003
5	Examples of Overuse, Underuse, Misuse, and Waste Over 30% of 600,000 Hysterectomies/yr Over 25% of 1,000,000 cardiac catheterizations/yr Over 40% of 110,000,000 outpatient antibiotic Rx/yr Female Medicaid patients aged 52 to 69 – only 55% receive screening mammogram Commercial HMOs – 20% diabetics without HbgA1c, and 50% without eye exam Surgical error: including all error types more than 1 error per case, and 14% of errors result in serious injury Avoidable delays in treatment and in adequate staffing result in 20% of errors
6	Summary of the Scope of the Outpatient Care Problem For Every: 1000 patients coming in for outpatient care 1000 outpatients who are taking a prescription drug 1000 prescriptions written 1000 women with a marginally abnormal mammogram 1000 referrals 1000 patients who qualified for secondary prevention of high cholesterol There Appear to Be: 14 patients with life-threatening or serious ADEs 90 who seek medical attention because of drug complications 40 with medical errors 360 who will not receive appropriate follow-up care 250 referring physicians who have not received follow-up information 4 weeks later 380 will not have a LDL-C, within 3 years, on record
7	Partners HealthCare Founded in 1994 Brigham and Women’s Hospital Massachusetts General Hospital Now includes: Community Physician Network 2 Rehab Hospitals 4 Community Hospitals Affiliated cancer hospital Common Clinical IT supported by Partners Information Systems
8	Partners HealthCare: Scale of the Integration Effort 55,000 email accounts 4,000 simultaneous users 35,000 paging transactions / day 25,000 order sessions/day 2,900,000 patients EMPI 3,700,000 visits captured 3,200 users of the LMR
9	Partners HealthCare: Scale of the Integration Effort 580,000,000 results in the CDR growing at a rate of 100,000 transactions/d 800 GB allocated 25 million specimens on file 8 million Radiology reports 75,000,000 images archived 2+ million Pathology reports 1+ million Operative notes 1+ million Discharge summaries 2+ million Microbiology Specimens
10	PHS Systems Integration Cvomponents
11	A Continuum of Clinical Decision Support
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15	Research Processes at PHS IS CQA Clinical & Quality Analysis, David Bates, Director www.partners.org/cqa CIRD Clinical Informatics Research & Development, Blackford Middleton, Director www.partners.org/cird Partners IS Research Council, John Glaser, Chair Center for Information Technology Leadership, Blackford Middleton, Chairman www.citl.org
16	Clinical Informatics Research Activities (CIRD & CQA) Asynchronous Clinical Event Monitor Bacteremia Prediction Rule BICS Event Engine Cholesterol Algorithm Clinical Documentation Drug Dictionary Support for LMR Drug-Drug Interactions ED Clinical Documentation Benefits Analysis End of Visit Nephros/Gerios Handbook KnowledgeLink Medication Alerts Medication Data Management Outpatient Clinical Reminders Patient Assessment Patient Computing Patient-Oriented Health & Disease Information Problem List Dictionary Results Manager Referral Manager Controlled Medical Terminology
17	Partners IS Research “Themes” Patient safety Ambulatory care Managing medical knowledge Remote provision of care Imaging informatics Optimizing patient care workflow IT support of clinical research Payer-provider integration
18	PHS IS Council Research Projects November 2003 Consumer Displays Digital Camera for Home Health Imaging Databases and Viewers Indoor Tracking Knowledge Management Medvance NLP Structured Doc Provision of Cardiac Services Smart Pen Tablet PC Vigilanz June 2003 Context-Sensitive Retrieval Financial Data Warehouse Home-based Monitoring Care of CHF Patients ID Management Web Services Wireless Devices March 2003 Black Box Warnings Improve Resident Practice Instant Messaging Interoperability of Data Medical Records Analytical Tools Nursing Communication Partners-wide Rules Engine Patient Data Synchronization October 2002 Clinical Messaging Family History Handheld Record IP Telephony Lipid Management Microsoft OS Partners Desktop Speech Integration Strong Authentication
19	Sample Research Projects KnowledgeLink Results Manager Patient Gateway ACPOE
20	Physician Information Needs Medical literature doubling every 19 years Doubles every 22 months for AIDS care 2 Million facts needed to practice Covell study of LA Internists: 2 unanswered clinical questions for every 3 pts 2/3 “answerable,” but only 1/2 of these ever answered, usually by another clinician
21	Unanswered drug questions Drug information is most frequent question 41% (Haynes 1990) 14% (Strasberg 1999) ~33% (Handbook stats) Drug info readily available Drug knowledge deficits are implicated in 29% of ADEs, and up to half of preventable ADEs (Leape 1995)
22	KnowledgeLink: Research Aims To describe how often and for what purposes physicians use knowledge links made available to them from within an electronic medical record To assess providers’ perspective on impact on care and provider satisfaction with links to real-time knowledge which are context-specific To assess the impact of providing these links on quality and utilization
23	KnowledgeLink: Study Design Randomize clinicians by clinic to KL/MDX (10), KL/SKOLAR (9), or no KL (12) ~300 providers per group attendings housestaff NPs 6 months to 1 year
24	Status: First 8 Months 5,656 queries (4,649 MDX, 1,007 Skolar) 329 distinct users (17.2/user, range 1-495) 3,448 distinct patients (1.6/pt, range 1-14) 1,373 distinct medications (4.1/med, range 1-65) Top 10 list: Lipitor, Atenolol, HCTZ, Lisinopril, Paxil, Celexa, Levoxyl, Dyazide, Protonix, Vioxx Frequency of KnowledgeLink use ~2x/mo/provider (median), range 0.05-26.2 4.6% of visits (based on subset of clinics)
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26	Effectiveness of KnowledgeLink About 80% of all KnowledgeLink queries are answered Not enough responses to say whether MDX (79%) is more effective than Skolar (71%), and for which types of queries 19% of queries by physicians cause them to alter a decision Skolar may have the edge over MDX (33% vs 17%) not enough data to determine with which types of queries KnowledgeLink has the most impact
27	Burden of Outpatient Test Result Management Per week, full-time PCP needs to review: 360 chemistry results (SMA7 = 7) 460 hematology results 12 pathology reports 40 radiology reports Heavy Time Investment 72 minutes (SD = 46) per day High level of dissatisfaction 57% of attending physicians report being not satisfied with the way they manage test results
28	A Risk Management Time Bomb ‘Failure to diagnose’ has been a rapidly rising cause of legal action Failures in the follow-up systems account for ¼ of diagnosis-related malpractice lawsuits
29	Results Manager Home Page Eric Poon, MD, PI/Project Mgr
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35	Evaluating the Impact of RM on Patient Safety 6 month, clustered, randomized controlled trial in 12 clinics Outcomes % of patients with timely follow-up Abnormal cholesterol Abnormal HbA1c Abnormal Mammograms Abnormal Pap smear Patient satisfaction regarding communication Physician satisfaction regarding result follow-up system
36	The Patient Gateway at Partners HealthCare: A Key Component to an Integrated Clinical Information Management Strategy at an IDN Investigators: Blackford Middleton, PI, Jonathan Wald (Co-PI, Product Manager), David Bates, Tejal Gandhi, Eric Poon, Richard Grant, James Meigs, Jeffrey Schnipper, Sapna Syngal, Research Staff: Lynn Volk, Amy Bloom, Lauren Weissman, Karen Burk Development/Implementation: Lisa Nelson, Dan Warmsley, Marianna Epstein, Linda Pedraza, Julian Butler, Raisa Feygin, Rudy Visokay, Mohan Babu, Andrea Fleming, Alison Gersten, Pat Carchidi Consultants: Patti Brennan, Vimla Patel, Dave Gustafson, Harvey Murff
37	Who Creates the Online Health Record?
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39	AHRQ Research Support RO1 “ Shared Online Health Records for Patient Safety and Care” Intervention Patient Journal with “topics” ARM 1: Meds/Allergies and Diabetes (or) ARM 2: Health maintenance and Family History Journal entry before a visit (for review during the visit) Changed prescription meds/allergies submitted at any time Pilot in 2^nd quarter 2004
40	Study Outcomes Snapshot Study patients who use an online record abstracted from their physician’s EMR to share health information and communicate will have improved: Clinical Outcomes [PRIMARY]: 1-2. ¯ADE rate, faster amelioration of side effects (Aim 1) 3. HM adherence to guidelines (Aim 2) 4. % of diabetics with Hba1c < 8.0 (Aim 2) 5. Detection of modifiable risk factors from family history (Aim 3) EMR Documentation [SECONDARY]: 6. accuracy of medications and alternative therapies (Aim 1) 7-8. rate of appropriate preventive care and screening, and improved diabetes status (Aim 2) 9. rate of family history documentation (Aim 3) Knowledge [SECONDARY]: 10-12. patient knowledge about their medications (Aim 1), prevention and diabetes guidelines (Aim 2) Communication & Satisfaction [SECONDARY]: 13-14. patient, family, and physician communication, and satisfaction with care (Aim 4)
41	Primary Care Account growth Feb 2002 to Oct 2003
42	Some Lessons Learned High enthusiasm among patients / staff (as expected) Reasonable volume of patient messages; replacing phone calls (high volume feared) Staff / physician time-neutral or time-saving (not a time sink) Few inappropriate messages (fears of portal misuse) More transactions à more value (even with small % of pts) Alternative workflows can be reduced (Voicemail to MDs, email to MDs, messages on paper, mailed letters) LMR workflow interactions are important
43	"Blackford Middleton" Blackford Middleton, MD bmiddleton1@partners.org