Electronic Medical Records: Moving into the Age of Digital Pain Management

Electronic Medical Records: Moving into the Age of Digital Pain Management Kevin L. Zacharoff, MD, FACIP, FACPE, FAAP

Disclosures Grant/Research Funding: Endo Pharmaceuticals, Actavis Salary: Inflexxion

Learning Objectives Describe the benefits of electronic medical health records Explain the possible downside to electronic medical health records Identify the role of the internet in patient education

Why Digital?

The Vision

Background Where’s the excitement about electronic medical records?

–Ease of sharing information across healthcare settings • Clinicians • Hospitals • Managed Care Organizations/Payers • Patients?

• Radiology Centers • Pharmacies • Public Health Departments

Background (cont’d) Policy makers hope that it will: –Reduce costs –Increase efficiency –Reduce medical errors

Some estimate that fully standardized health care information exchange and interoperability (HIEI) will save approximate $77.8 Billion1 1: Walker, J. et Al. The Value of Health Care Information Exchange and Interoperability. Health Affairs 2005.

HITECH Support for passage of the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009, which dramatically expanded federal expenditures for the adoption of health information technology, rested heavily on this argument1

1. Blumenthal D. Wiring the health system—origins and provisions of a new federal program. N Engl J Med. 2. 2011;365(24):2323–9

Background  Washington said it has to happen: – Reduce delays and costs associated with paper-based ordering and reporting – Provide better access to longitudinal test results – Eliminate errors – Improve convenience – Facilitate: • Complete medical list formation –Reducing duplicate Tx –Drug-drug interactions –Adverse drug events –Abuse M. Allen, “Bush Touts Plan for Electronic Medicine, "Washington Post, 28 May 2004.

Background (cont’d)  Additional benefits: – Automated refill alerts – Information to clinicians about refill practices (by patients) – Auto-completion of insurance forms required for certain medications – Notification of clinicians and patients about recalls/other information – Uncover new side effects – Improve formulary management

Background (cont’d)  Additional benefits: – Facilitated reporting of important information from HCPs – Reduce fragmentation of care • Scattered records • Improved referral patterning

– Earlier recognition of emerging disease outbreaks and biosurveillance – Patient safety – Quality of care

Are There Any Downsides?  Reality check – A recent study1 looked at the records of 28,741 patient visits to a nationally representative sample of 1,187 office-based physicians and showed • People might actually order more diagnostic tests and procedures due to facilitated access to digital imaging procedures • A doctor with access to digital imaging access is 40-70% more likely to order another test • Same thing with blood work

McCormick,D. et al. Giving Office-Based Physicians Electronic Access to Patients’ Prior Imaging and Lab Results Did not Deter Ordering of tests. Health Affairs March 2012 vol. 31 no. 3 488-496.

Reality Check What Happens In Large Institutions With IT Departments And Staff May Not Reflect What Front-line Practitioners Do

Reality Check (cont’d)  “The availability of an electronic health record in itself had no apparent impact on ordering; electronic access to test results appears to have been the key. These findings raise the possibility that, as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering.”  “We conclude that use of these health information technologies, whatever their other benefits, remains unproven as an effective costcontrol strategy with respect to reducing the ordering of unnecessary tests” McCormick,D. et al. Giving Office-Based Physicians Electronic Access to Patients’ Prior Imaging and Lab Results Did not Deter Ordering of tests. Health Affairs March 2012 vol. 31 no. 3 488-496.

Oy Vey!

The Dubious Promise of Digital Medicine  BusinessWeek April 23, 2009  Under the federal stimulus program enacted in February, hospitals can seek several million dollars apiece for tech purchases over the next five years  Individual physicians can receive up to $44,000

– “These carrots should encourage the proliferation of technology that will computerize physician orders, automate dispensing of drugs, and digitally store patient records” – “If providers participate broadly, those files are supposed to be accessible no matter where a consumer goes for treatment” – “President Barack Obama says the changes will improve care, eliminate errors, and eventually save billions of dollars a year…”

– There's also a stick: The federal government will cut Medicare reimbursement for hospitals and medical practices that don't go electronic by 2015

It’s Still a Bit Messy

The Value Proposition An analysis of four years of Medicare data published in March only marginal improvement in patient safety due to electronic records—specifically, the avoidance of two infections a year at the average U.S. hospital

McCormick,D. et al. Giving Office-Based Physicians Electronic Access to Patients’ Prior Imaging and Lab Results Did not Deter Ordering of tests. Health Affairs March 2012 vol. 31 no. 3 488-496.

Cited Problems Pharmacy errors1 No way to report problems2 “Alert fatigue”3 INCREASES in dosage errors4

1. Geisinger Clinic, PA 2. The Joint Commission 3. Seattle Children’s Hospital 4. Children’s National Medical Center Washington, DC

An Interesting Story  Doctor’s Pride: A Hurdle to Digital Medicine  Business Week April 23rd 2009  A forerunner in New England found that some physicians would sooner cut ties than see elite status threatened  In 2004, Partners Health System required that the 4,500 doctors with admitting privileges install an EMR in their offices (~$25,000 each)  Docs didn’t like the emphasis on tying all staff together

Isn’t There Any GOOD NEWS?  Sure there is!

– Portability is something we all could benefit from • Films • EKGs • Consults

– Communication with all stakeholders – Speed – Access to information – Education

There’s Plenty of Good News

Where’s the Good News in Pain Management?

More Good News

We Can Fix Things…

Benefits of “Digital” Medicine  Standardize practices  Improve documentation  Improve quality  Enhance communication  Save space  Improve efficiency  Clinical guidance  EDUCATION

Flow of Information The paternalistic approach to medical decision making is changing as patients have more access to information, and increasingly pose questions requiring answers about therapeutic choices Patients now often advise each other as a way to become educated and “informed consumers”

The Internet And Patient Information  What is the role of the internet in patient education?  Schwartz et al.1 surveyed 1289 Family Medicine patients on internet use – 65% reported access to the internet • 74% of those with access had used the Internet to find health information for themselves or family members

 Disease-specific information was most frequently sought – Followed by medication information • Followed by information about nutrition and exercise 1. Schwartz, et al. Family Medicine Patients’ Use of the Internet for Health Information: A MetroNet Study.

J Am Board Fam Med 2006;19:39–45

Schwartz (Cont’d)  Patients determine website accuracy by

– Endorsement of the site by a government agency or a professional organization – Their own perception of reliability of the website source – Understandability of the information

 Almost 90% attempted to verify the information they obtained  A majority had discussed website information with their physicians  The physicians surveyed (n= 92) underestimate the proportion of their patients who used the Internet for health information  A total of 36% of physicians said at least one patient per week brought in Internet health information  63% said they had suggested a specific website to their patients

1. Schwartz, et al. Family Medicine Patients’ Use of the Internet for Health Information: A MetroNet Study.

J Am Board Fam Med 2006;19:39–45

painACTION.com Features  Lessons – Online, interactive lessons that offer practical pain selfmanagement skills – Multimedia-enhanced to engage users

 Tools – Interactive tools educate patients about different aspects of managing pain – Integrated with multimedia to convey complex information in an engaging, easy-to-understand way

Medication Safety

Skill-Building Tools

Back Pain RCT: IMMPACT Measures  Chronic Pain Coping Inventory  Depression Anxiety Stress Scale  Oswestry Disability Questionnaire  Patient Global Impression of Change Scale  Pain Catastrophizing Scale  Brief Pain Inventory  Fear Avoidance Beliefs Questionnaire  Pain Self-Efficacy Questionnaire  Work Productivity and Activity Impairment Questionnaire

Psychosocial Outcomes  Reduced stress  Increased coping and use of social supports  Website participants reported a greater average improvement in their condition at post-tests

Chiauzzi et al., painACTION-back pain: A Self-management Website for People with Chronic Back Pain. Pain Medicine July 2010

Clinically Significant Findings  painACTION participants evidenced:  Clinically significant decreases from baseline to post-intervention in: – Depression (15.5%) – Anxiety (20.1%) – Stress (16.5%)

 12.3% decrease in current pain from baseline to post-intervention (7% decrease in controls)  At least a minimal improvement in condition (56.6%, compared to 33.0% of controls)

Online vs. Pain Clinic Decrease in self-reported “worst pain” from baseline to post-test Decrease in average pain from baseline to the threemonth follow-up assessment Increase in coping self-statements from baseline to threemonth follow-up

Migraine Study Results Increased headache self-efficacy Increased use of relaxation Increased use of social support Decreased pain catastrophizing Decreased depression Decreased stress Bromberg et al. In press. (2011)

Complementary Print Materials Your Guide to Pain Management

ACTIONSteps

The Future  Ultimately, the following will likely happen as a result of the digitalization of medicine: – Speed the flow of knowledge, and store it efficiently memories – Guide and assist in patient care itself, wherever the clinician or patient may be – Free physicians from paper records and bills – Markedly improve and enrich communications with patients – Facilitate collaboration between clinicians in consultation and in learning

Challenges Exist

Challenges Exist (cont’d)  “Many physicians see the use of electronic health record systems as a distraction from patient care” according to a survey by online physician community Sermo and EHR provider athenahealth

McCann, Majority of Physicians Say EHRs Interfere With Care. Healthcare IT News, 6/14/12

Challenges Exist (cont’d) 44% said of that EHR systems are not designed with physicians in mind, up from 32% in 2011 32% said that they have a favorable opinion of EHR systems, down from 39% in 2011 15% said that they believe EHR systems somewhat or significantly worsen patient care, up from 11% in 2011

McCann, Majority of Physicians Say EHRs Interfere With Care. Healthcare IT News, 6/14/12