1 hit return on investment: evaluating progress in a sea of change john hsu, md, mba, msce ahrq...
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HIT Return on Investment:Evaluating Progress in a Sea of Change
John Hsu, MD, MBA, MSCE
AHRQ Conference
27 September 2007
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HIT Background
Great potential for transforming clinical care, especially for patients with chronic diseases
Adoption of HIT across the U.S. is limited but growing
Actual benefits of HIT unclear: Initial benefits of HIT depend on how routinely and systematically
clinicians use the HIT tools and resulting information Little information on HIT effects in the ambulatory setting with
commercially-available systems
Actual benefits and costs of HIT are difficult to quantify Comprehensive identification Methodological challenges
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Preliminary Results - IMPACT Study
Impact of Information Technology on Clinical Care: An Evaluation of the Technology on Quality, Safety and Efficiency of Chronic
Disease Care
John Hsu, MD, MBA, MSCE (KP DOR)Ilana Graetz (KP DOR)Huihui Wang (KP DOR)
Jie Huang, PhD (KP DOR)Mary Reed, DrPh (KP DOR)
Bruce Fireman, MA (KP DOR)Joseph Selby, MD, MPH (KP DOR)
Yvonne Zhou, PhD (KP)Jim Bellows, PhD (KP CMI)Naomi Bardach, MD (UCSF)
Julian Wimbush (UCB)Tom Rundall, PhD (UCB)
Robert Miller, PhD (UCSF)Richard Brand, PhD (UCSF)
Funding: AHRQ R01HS015280
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• Design: – Longitudinal study with quasi-experimental changes in
exposure to HIT, and using a pre-post analytic design with concurrent controls
• Study Period: 2004-2008
• Population: IDS Members with any of five chronic diseases in January 2004 (Asthma, CAD, DM, HF, Htn)
• Data: - Automated databases- Annual surveys
Overview
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Basic HIT Tools
CIPS eChart eRx/eRefill eConsult
First Available: 1995 March 2004
Functions:
Data-Review
Documentation
Order-Entry
Communication
Paper-alternative: No Yes Yes Yes
Integrated: Not integrated with other applications (i.e., need log onto each application separately)
Description:
Viewing lab results
Viewing medication list
Writing free-text visit notes
Using standard note templates
Viewing medication list
Viewing medication allergies
Entering orders for new prescription or refills
Requesting referrals or consultations
Sending messages to other providers
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First Available: Staggered implementation (2005-2008)Functions:
Data-Review
Documentation
Order-Entry
Communication
Paper-alternative: No
Integrated: Fully Integrated
Description:
•Viewing medication list, allergies, lab results•Using standard note templates & writing free-text visit notes•Order new prescription or refills with decision support•Ordering Disease-specific sets (drugs and labs)•Sending messages to other providers & requesting referrals or consultations•Sending and receiving messages from patients•Point-of-care access to decision-support tools– including:
–Online references and resources for current treatment guidelines –Care Management Institute protocols, and standard tests/screens
KP HealthConnect Ambulatory Suite
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Potential Benefits of HIT
• Improved information availability (value of information)
• Clinical benefits• Financial benefits: e.g., greater efficiency, lower
administrative costs, better coding
Benefits predicated on clinician use of HIT tools
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HIT Use
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HIT Implementation and Use
0
20
40
60
80
100
4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6
2004 2005 2006
Percen
t o
f V
isit
s U
sin
g H
IT
KPHCe-Chart
* Among office visits in department of Medicine or Family Practice
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CPOE Implementation and Use
0%
10%
20%
30%
40%
50%
60%
70%
4 5 6 7 8 9 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2004 2005 2006
Perc
ent o
f New
Pre
scrip
tions
Usi
ng H
IT
* New prescriptions are defined as new prescriptions doctor wrote, can be refills for existing drugs or completely new drugs
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HIT Use
• Implementation ≠ use
• Use of one type of HIT ≠ use of all HIT tools
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Information Quality
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Data Availability: Diagnoses Completed on Visit Date
* Among office visits in department of Medicine or Family Practice
0
10
20
30
40
50
60
70
80
90
1004 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2004 2005 2006
Per
cen
t o
f V
isit
s w
ith
Sam
e-d
ay D
iag
no
sis
En
try
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Clinical Benefits
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Methodological Challenges for Assessing Clinical Benefits
• Measures of use
• Temporal trends - concurrent control groups
• Patient- and physician-level differences
• Reliable pre-implementation clinical data - differentiating
documentation vs. care
• Multi-level effects
• Adequate power
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Methods
• Study Period: 04/2004-12/2006
• Study Population– Active KPNC members who continuously enrolled during the study
period– 18 years and older as of 04/01/2004– In diabetes registry as of 1st quarter of 2004 – Members in 5 medical centers where KPHC implemented before
07/2006 during the study period – In teams which existed all the time during the study period – With at least one LDL measurement in pre-HIT period and one in post-
HIT period
• Predictor Measures: Presence of HIT (HealthConnect)
• Model: Mixed model with random effects at PCP and Patient level, adjusted for patient age, gender, race/ethnicity, neighborhood SES, time of measurement and Medical centers
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Definitions of Presence of HIT
Definition 1: Medical center level KPHC rollout schedule– HIT=0: before KPHC was implemented at the first team in the medical
center– HIT=1: within six months after KPHC was implemented at the first team
in the medical center – HIT=2: six months after KPHC was implemented at the first team in the
medical center
Definition 2: Primary care team level actual use– HIT = 0: low use (<80% at team level) of eChart or KPHC– HIT = 1: starting from the first month when eChart used >=80%– HIT = 2: starting from the first month when KPHC used >=80%
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Mean LDL in Each Month in KPNC
90
92
94
96
98
100
4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2004 2005 2006
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Association between HIT and LDL
Estimate 95% CI
1. Implementation at Medical Center (roll-out schedule)
Before KPHC 1.00 ref. group
First 6 months of KPHC -0.50 -1.15 0.15
6+ months of KPHC -0.64 -1.58 0.30
2. Actual use by Primary Care Team (% of total visits)
Low HIT use (<80% of visits) 1.00 ref. group
EChart used in >80% of visits -0.89 -1.55 -0.23
KPHC used in >80% of visits -1.72 -2.68 -0.76
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Costs
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Investment
• Investment costs– Equipment– Personnel/productivity– Training
• Maintenance costs– IT support staff– Future upgrades– Continued training
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Other Relevant Features
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Dynamic Environment
• Changes in HIT– Decision support– Information use
• Changes in Care Delivery– Clinical coordination– Delivery system
• Changes in Medical Therapy– Information on effectiveness– Dissemination of new knowledge
• Changes in the Market– Payment features, e.g., risk adjustment, reporting, performance incentives– Payment mix
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Conclusions
• Benefits– Some potential clinical benefits related to better information at the
point-of-care– Unclear benefits associated with improvements in clinical
information at the system level– Transaction benefits perhaps easiest to quantify– Financial benefits depend market and reimbursement mix
• Costs– Investment costs beyond equipment costs can be difficult to
quantify– Maintenance costs also important
• Dynamic/changing systems and markets....
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Summary: Need for Better Empirical Studies
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HIT as Basic Infrastructure