C. Martin Harris, M.D., M.B.A. Holly D. Miller, M.D., M.B.A.

Transcription

1 C. Martin Harris, M.D., M.B.A. Holly D. Miller, M.D., M.B.A. HIMSS 2003

2 Who We Are C. Martin Harris, M.D., M.B.A. Chief Information Officer Executive Director of e-cleveland Clinic Holly D. Miller, M.D., M.B.A. Director: e-product Development Director: Clinical Internet Systems

3 Learning Objectives Understand the strategy for delivering health information and clinical care services over the Internet in the 21 st Century Learn the deployment tactics for delivery of patient specific Internet health care information and clinical care

4 Learning Objectives Understand how to optimize the positive aspects and minimize the negative aspects of instantaneous access to on-line health information for both patients and providers Understand how high speed Internet access to the home will facilitate advanced patient-centric e-health initiatives

5 Overview Internet Use in Medicine The Electronic Medical Record Backbone The e-volution of Healthcare Services Internet Patient Access Internet-based Second Opinions Internet Remote Monitoring of Patient s Medical Devices

6 Internet Use in Medicine What is the current use of computers in a typical physician office? Is the Internet used in practice today? What is the status of the electronic medical record use in medical practice?

7 Practicing Physicians 800, , ,000 Online = Accessed at all in the last 12 months 554, ,000 (95%) The Internet is Essential to My Practice 341,000 (62%) 200, ,000 (21%) 0 All Docs OL Docs Daily Users Professional Based on American Medical Information Users Industry Universe Benchmark Deloitte Consulting /

8 Computer System in Office 15% 12% 9% 85% 88% 91% No Yes All Docs Daily Users Prof Users Deloitte Consulting /

9 Internet Access at the Office Prof Users 91% 9% Daily Users 83% 17% All Docs 74% 26% Yes No Deloitte Consulting /

10 Use of Electronic Medical Records Prof Users 19% 80% 1% Daily Users 14% 85% 1% All Docs 12% 87% 1% Deloitte Consulting / Yes No Don't Know

11 My affiliate hospital(s) have computerized order-entry entry systems at the point of care. 8% 7% 7% 51% 51% 50% DK No Yes 41% 42% 43% All Docs Daily Users Prof Users Deloitte Consulting /

12 What Do Patients Want? Who is online? What services do patients want? Does offering patient services influence patient choices?

13 Who is Online? 66% of all adults in the USA are online (from home, office, school, library or somewhere else)

14 Consumer Trends: What Patients Want 4/2002 Online Harris Interactive Nationwide Survey of Adults: 90% would like to be able to communicate with their physicians online 77% would like to be able to ask questions in lieu of a visit

15 Consumer Trends: What Patients Want Nationwide Survey of Adults: 71% would like to be able to make appointments 71% would like to be able to refill prescriptions 70% would like to be able to receive the results of medical tests

16 Harris Interactive Nationwide Survey (Cont.) More than a third of those online say they would be willing to pay: 37% say they would be willing to pay out-of-pocket for the ability to communicate online with their physicians

17 Harris Interactive Nationwide Survey (Cont.) 55% say that Internet access to services and providers would influence their choices of doctors and health plans 12 % say it would influence their choice of health plans "a great deal. 14% say this would influence their choice of doctors "a great deal."

18 An e-volution e Strategy Shared Vision: The Internet as Part of the Practice of Medicine e-enable the Clinical Practice Model e-extend and Enhance Clinical Services

19 From Content to Care The Implementation Strategy Value to the Patient Content Electronic Medical Record Internet Access to Professional Services Internet Access to Medical Information Internet Based Patient Monitoring Internet Based Patient Interventions Past Present Future

20 Practical e-volution e Steps EMR backbone e-services Patient access to services and records My Chart: Your Personal Health Connection On-line second opinion My Consult Internet monitoring of patient s medical devices My Monitoring

21 Setting The Cleveland Clinic 1,286 Professional Staff 110 Research Staff 2,278,442 Outpatient Visits per year 52,330 Hospital Admissions per year

22 The Electronic Medical Record Backbone Workflow Documentation Ordering Results

23 The Electronic Medical Record Users Physicians = 538 Doctors Schedulers Nurses Residents/ Fellows = 532 Residents/ Fellows Front Desk End Users = 2,705 (*as of 10/31/02) Nurse on Call Patients

24 Electronic Medical Record Electronic Medical Record Workflow Workflow View Schedules In-Basket Messaging Patient Lookup Remote Access

25 Results

26 Medication Renewal

27 On-Line Documentation Note is Available to all Practitioners in Real Time Structural Documentation Tools Facilitate: Note Completeness Coding Research

28 Physician Order Entry Links Order with Diagnosis Facilitates Future Ordering Enhances Patient Safety: Legibility Reasonable Doses Only Alerts

29 Drug Interaction Alert Drug Interaction Alert

30 Practical e-volution Steps EMR backbone e-services Patient access to services and records My Chart: Your Personal Health Connection On-line second opinion My Consult Internet monitoring of patient s medical devices My Monitoring

31 Patient Services View medical information View health reminders View schedule Appointment request Prescription renewal Value for Patients Reduced telephone waiting time 24-hour access Directed access to healthcare information

32 My Chart: Condition-Specific Info

33 My Chart: Health Maintenance

34 My Chart Lab Results

35 My Chart: Medications List

36 MyChart: Request Appointment

37 MyChart Utilization Statistics Health Reminder 7% Administration 13% Appointments 32% Problem List 14% Test Results 15% Medication Management 19%

38 Practical e-volution Steps EMR backbone e-services Patient access to services and records My Chart: Your Personal Health Connection On-line second opinion My Consult Internet monitoring of patient s medical devices My Monitoring

39 The Second Opinion Process Symptoms Primary Diagnosis Recommendation Second Opinion Confirmation Alternatives

40 What is an Internet Second Opinion Second opinions only Primary diagnostic work up required Common second opinion diagnoses covered Opinion sent to primary physician, upon patient request Integrated into electronic medical record based operational workflow

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42 Start of request opinion process

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44 Step 6: Checklists Below is a list of materials you need to mail To the Cleveland Clinic in order for your second opinion to be rendered The materials include the following: List of medical materials Consent form Mailing instructions and labels Patient sends appropriate support information

45 Second Opinion Recommendations: We reviewed his case in our multidisciplinary brain tumor board. Imaging was indeed most consistent with a right trigeminal schwannoma The consensus recommendation was for microsurgical removal by an experienced skull base surgeon with consideration of radiosurgery for any (if any) residual tumor. This recommendation also considered the alternatives of observation, radiotherapy, radiosurgery (Gamma Knife, CyberKnife, Linac), and drug therapy. Among these, the only reasonable options for a progressively symptomatic lesion such as this were thought to be microsurgery or radiosurgery. Reports (presentations and publications) by experienced skull base surgeons, if accurate, have shown low operative morbidity from surgical resection. Surgery (complete resection) is thought to have the best durability (i.e., control rate). Complications include facial numbness, change in bite, double vision, inability to raise that eyelid and, less commonly stroke, difficulty with speech, limb weakness on the opposite side, infection or other wound problems and, even less common, catastrophic outcomes or systemic complications. The last would be very uncommon at your age. Complications from surgery by skull base surgeons with limited experience would probably be more likely. Surgery also provides a tissue diagnosis in the unlikely event that this is something other than a schwannoma. Our experienced skull base surgeon is Dr. Joung Lee. Radiosurgery is obviously appealing because of the reported low incidence of early complications and short time of recovery. Fractionated treatments should have lower complication rates that single fraction radiosurgery (the more fractions the better considering conventional dose per fraction) but with, theoretically, lower control rates with more fractions. Reliable, long-term follow-up of radiosurgery for schwannomas (other than acoustic neuromas) are lacking this is even a greater problem for fractionated treatments. Radiosurgery may increase the risk of surgery if surgery is necessary from a radiosurgical failure. Tissue diagnosis is generally not worth the additional risk (open or needle biopsy). Radiosurgery may infrequently lead to radiation injury of the adjacent brain causing seizures, memory difficulty, weakness, headache, or no symptoms at all (but changes on scans). Catastrophic outcomes from radiosurgery are very rare.

46 Participating Specialties Grown over a 6 month Period Cancer Cardiology Colorectal Surgery Dermatology Eye Institute Gastroenterology General Surgery Gynecology Neurology Neurosurgery Orthopaedics Otolaryngology Pathology Pediatrics Plastic Surgery Pulmonary and Critical Care Medicine Radiology Radiation Oncology Spine Center Thoracic and Cardiovascular Surgery Urology Vascular Medicine Vascular Surgery

47 My Consult Second Opinion Distribution International Market 17% Contiguous Market 41% National Market 42%

48 Practical e-volution Steps EMR backbone e-services Patient access to services and records My Chart: Your Personal Health Connection On-line second opinion My Consult Internet monitoring of patient s medical devices My Monitoring

49 The Vision Medical devices will be used: Present time frame: To monitor care Near future: To deliver medical care

50 Clinical/ Technology Model Medical Devices Implanted Cardiac Devices Home Health and Disease Specific Monitoring Devices Other Monitoring Devices (Brain, GI, Cardiac, Ortho, etc.) Internet Electronic Medical Record

51 Patient or Device Initiated Transmission Medical Devices Defibrillator PD Dialysis Brain Stimulator Physician Effects Device Driven Intervention Remotely Over the Internet Internet Transmission Internet Transmission Encounter Stored in the EMR

52 Adoption Hurdles Standards Requirements The development of communication infrastructure and data structure standards in medicine The universal adoption of these standards

53 Paradigm Shift in the Practice of Medicine E-Health Strategy Development Electronic Medical Record Foundation Creation of e-health Services Expanding Market Potential

54 Questions