emerging hit incentive programs: physician responses health information technology summit march 8,...
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Emerging HIT Incentive Programs: Emerging HIT Incentive Programs: Physician ResponsesPhysician Responses
Health Information Technology SummitMarch 8, 2005
Peter Basch, MD David Kibbe, MDMedical Director, eHealth Director, AAFP’s Center for MedStar Health Health Information Technology
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Bio’sBio’s
Peter Basch, MD General internist Medical Director, eHealth –
MedStar Health Co-Chair PEHRC Co-Chair of the Small Practice
Workgroup of eHI
David C. Kibbe, MD, MBA Family physician Director, Center for Health
Information Technology Co-Chair PEHRC Co-Chair of the Small Practice
Workgroup of eHI
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OverviewOverview
Barriers to HIT adoption Why are incentives necessary? Responses to key HIT incentive programs
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Risks / barriers to HIT adoption?Risks / barriers to HIT adoption?
Physicians are not computer phobic Physician culture is pro-quality / safety Computers are affordable / reliable Connectivity is affordable / reliable Software is reliable, and often affordable
Why haven’t physicians accelerated adoption of HIT?– Risks / barriers to adoption– Risks / barriers to “interconnectivity”– “Questionable” (negative to very negative) business case
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Lowering Risks / Barriers to Lowering Risks / Barriers to EHR AdoptionEHR Adoption
Barrier Solution Current WorkConfusion about product and company
EHR product certification
Certification Commission on HIT (CCHIT)
Not knowing which EHR is best for which type of practice
Trusted specialty-specific EHR guidance
AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others
High prices Affordability and transparency
Buying collaboratives - Medical professional and specialty societies
Risk of implementation failure
Trusted technical advice
AAFP’s CHiT, ACP’s PMC, QIOs
Wide variability in contracting and business practices
Standard contracting language, RFP guidance
AAFP’s Partners for Patients, ACP’s PMCeHealth Initiative
Difficult and expensive access to external information
Standards-based solutions for labs, imaging centers, etc
California Health Care Foundation, eHealth Initiative
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Lowering Risks / Barriers to Lowering Risks / Barriers to EHR AdoptionEHR Adoption
Barrier Solution Current WorkConfusion about product and company
EHR product certification
Certification Commission on HIT (CCHIT)
Not knowing which EHR is best for which type of practice
Trusted specialty-specific EHR guidance
AAFP, ACP, other medical specialty societies; KLAS, HIMSS, others
High prices Affordability and transparency
Buying collaboratives - medical professional and specialty societies
Risk of implementation failure
Trusted technical advice
AAFP’s CHiT, ACP’s PMC, QIOs
Wide variability in contracting and business practices
Standard contracting language, RFP guidance
AAFP’s Partners for Patients, ACP’s PMCeHealth Initiative
Difficult and expensive access to external information
Standards-based solutions for labs, imaging centers, etc
California Health Care Foundation, eHealth Initiative
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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity
Barrier Solution Current Work
Information overloadInformation out of contextCare confusion
Potential for ↑duty and risk in an interconnected environment
Potential for ↑duty and risk with use of clinical decision support
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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity
Barrier Solution Current Work
Information overloadInformation out of contextCare confusion
New clinical protocols for interconnectivity
Potential for ↑duty and risk in an interconnected environment
Dialog and clarity with legal / policy communities
Potential for ↑duty and risk with use of clinical decision support
Dialog and clarity with legal / policy communities
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Lowering Barriers to Lowering Barriers to InterconnectivityInterconnectivity
Barrier Solution Current Work
Information overloadInformation out of contextCare confusion
New clinical protocols for interconnectivity
CCR
Potential for ↑duty and risk in an interconnected environment
Dialog and clarity with legal / policy communities
???
Potential for ↑duty and risk with use of clinical decision support
Dialog and clarity with legal / policy communities
???
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Creating the Business CaseCreating the Business Case
Barrier Solution Current WorkNo money available for IT investment
Access to capital eHealth Initiative Financing Working Group
Questionable business case for IT adoption
Pay-for-IT use National Group for the Advancement of HIT
Negative business case for quality
Pay-for-performance National Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog
Negative business case for information management
Pay-for-activities of information management
National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB
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Creating the Business CaseCreating the Business Case
Barrier Solution Current WorkNo money available for IT investment
Access to capital eHealth Initiative Financing Working Group
Questionable business case for IT adoption
Pay-for-IT use National Group for the Advancement of HIT, ACP
Negative business case for quality
Pay-for-performance National Group for the Advancement of HIT, eHI, DOQ-IT, BTE, Leapfrog
Negative business case for information management
Pay-for-activities of information management
National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB
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Creating the Business CaseCreating the Business Case
Barrier Solution Current WorkNo money available for IT investment
Access to capital eHealth Initiative Financing Working Group
Questionable business case for IT adoption
Pay-for-IT use National Group for the Advancement of HIT, ACP
Negative business case for quality
Pay-for-performance National Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog
Negative business case for information management
Pay-for-activities of information management
National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB
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Creating the Business CaseCreating the Business Case
Barrier Solution Current WorkNo money available for IT investment
Access to capital eHealth Initiative Financing Working Group
Questionable business case for IT adoption
Pay-for-IT use National Group for the Advancement of HIT, ACP
Negative business case for quality
Pay-for-performance National Group for the Advancement of HIT, ACP, eHI, DOQ-IT, BTE, Leapfrog
Very negative business case for information management
Pay-for-activities of information management
National Group for the Advancement of HIT, ACP, BTE, CCIP, CMHCB
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No money available…No money available…
For physicians – access to loans is not a problem… But willingness to borrow money for an uncertain ROI is. Nevertheless – may be important for some doctors
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Case for IT adoption (Case for IT adoption (per se)per se)
Successful IT adoption by itself has not been shown conclusively to improve quality or safety (except where quality has been specifically incented)
Without further specifying process / outcomes measures as a requirement of reimbursement – it is clear that HIT will be used to further the existing business case = ↑ volume and “right coding”
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The business case for quality and The business case for quality and information managementinformation management
Computers are affordable Networking is affordable Broadband is affordable EHR software is affordable Interconnecting to all necessary sources of information is
affordable
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The business case for quality and The business case for quality and information managementinformation management
Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will
hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion
Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity
Activities of quality care = the above, and population and disease management, non-visit based care, and care coordination
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Basic EHRBasic EHR
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Decision support for patientDecision support for patient
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Integrated registry – proactive Integrated registry – proactive use by clinicians and staffuse by clinicians and staff
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Advanced EHR + Registry + eVisitsAdvanced EHR + Registry + eVisits
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Advanced EHR + Registry + eVisits + HIEAdvanced EHR + Registry + eVisits + HIE
CDE
Security / MPI
Decentralized model
Imaging Centers
Labs
Community Hospitals
Tertiary Care Hospitals
PBMs
Payors Public Health
PCPs and Specialists
Patients
• Patient info• Visit list• Prob list• Med list• Allergy list• CCR
• Patient info• Visit list• Prob list• Med list• Allergy List• Discharge Sum • ED Reports• CCR
• Reports• Images• Med lists• Formulary
• Bio-surveillance• Safety, quality, efficiency indicators
• Diagnosis• Claims History• Eligibility• Referrals• Authorizations• Claim Submission• Claim Status• Claim Remittance
• Personal Health Record
Long-term Care Home Health
Outcomes Measures
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The business case for quality and The business case for quality and information managementinformation management
Computers are affordable Networking is affordable Broadband is affordable EHR software is becoming more affordable Interconnecting to all necessary sources of information will
hopefully become affordable (perhaps free) – and may (if we are lucky) improve quality and safety, and not result in information overload, “cookbook medicine,” and/or care confusion
Quality care = (information) (knowledge) (context) Quality care = “micro-tasking” Quality care = ↑ time, cost, complexity
Activities of quality care = the above, and population and disease management, non face-to-face care, and care coordination
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Existing P4P initiatives Existing P4P initiatives
Pros Cons
Free software / devices
Paid eCare
Use of administrative data for P4P
Use of administrative + clinical data for P4P
= bad, to = bad, to = completely meets goals= completely meets goals
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Preferred P4P initiatives Preferred P4P initiatives
= bad, to = bad, to = completely meets goals= completely meets goals
Pros Cons
Care coordination / management fee
Paid eCare*
Staged pay-for-use → data submission →
performance
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SummarySummary
There are many risks and barriers to HIT adoption that can and should be lowered
Interoperability only sets the stage – meaningful clinical interconnectivity will determine its value
Payers must create a sustainable positive business case for adoption and optimal use (recognizing the implications to the practice)
HIT adoption per se may add little or no net cost to a practice, and may produce little or no net value for the patient – may require a “jump-start,” but will not require ongoing incentives
Integration of HIT into some practice settings can lead to ↑ quality/safety/efficacy/access (↑ HIT value), and doing so will ↑ provider time/cost/complexity (↑ practice costs) – requires ongoing structural reimbursement changes
Incentives should not just be based on numerical targets, as healthcare transformation enabled thru HIT includes other key elements, such as meaningful care coordination / management, collaboration with patients, and optimal use of non face-to-face care (none of which will occur without fundamental reimbursement reform)