HealthCare Information HealthCare Information Technology Technology

Blackford Middleton, MD, MPH, MScDirector, Clinical Informatics Research & Development

Chairman, Center for IT Leadership

OverviewOverview

What is Health IT? How Does Health IT impact healthcare? What is the Evidence-base for HIT? What is the Promise of HIT? Where do we stand on HIT Adoption? What is the Potential Value of HIT? How is Health IT Policy Derived Today? What are Policy Options to Stimulate HIT? Possible focus areas to move the ball

What is Health IT?What is Health IT?

Hospital – many systems Computer-based Provider Order Entry (CPOE) Electronic Medication Administration Record (eMAR) Clinical Data Repositories Ancillary Systems (Lab-chemistry, Lab-micro, Blood Bank, Radiology,

Pharmacy, Pathology, etc. Devices: Smart Pumps, Ventilators, EKG, ABGs… Financial: Revenue-cycle Management

Clinic Electronic Health Records (Electronic Medical Records) Practice Management System

Patient Personal Health Records

Payors – also may have PHRs Free-standing (community): any of the above

How Does Health IT impact How Does Health IT impact healthcare?healthcare?

Information management and processing Making the bill Processing specimens (ancillary departments)

Information access Hospital information systems, EMRs

Data analysis -- financial Data analysis – clinical operations/research Clinical Decision Support Information exchange

How Does HIT Improve Healthcare?How Does HIT Improve Healthcare?

Clinical Processes Streamline, structure order process Ensure completeness, correctness Supply patient data Charge display Redundant test reminders Structured ordering with counter-

detailing Consequent or corollary orders

Other EMR Process Benefits Reduced transcription costs Reduced chart pulls Improved clinical messaging and

workflow Improved charge capture and accounts

receivable Improved referral coordination Improved patient communication and

service

Medication Utilization Perform drug interaction checks Check for duplicate medications Brand to generic substitutions Calculate and adjust doses based upon

age, weight, renal function Alternative cost-effective therapies Formulary compliance Indication-based ordering

How does healthcare information How does healthcare information exchange impact the bottom line?exchange impact the bottom line?

Largely, TBD… Expected effects

Reduced healthcare information management labor costs

Reduced duplicative tests and procedures Reduced fraud and abuse Improved service delivery efficiency Improved patient convenience Reduced medical error

What is the Promise of HIT?What is the Promise of HIT?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Beta blocker after AMI

Breast cancer screening

Cervical cancer screening

Cholesterol screening

Cholesterol after AMI

LDL < 130 after AMI

Colorectal cancer screening

Diabetes: HgbA1c done past year

Diabetes: Adequate control

Diabetes: Cholesterol measures

Diabetes: Cholesterol controlled

Diabetes: Eye Exam

Diabetes: Renal Exam

Hypertension: BP <= 140/90

Flu shot (over 65)

Pneumococcal vaccine (over 65)

Mental health followup after discharge

Before

After

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Beta blocker after AMI

Breast cancer screening

Cervical cancer screening

Cholesterol screening

Cholesterol after AMI

LDL < 130 after AMI

Colorectal cancer screening

Diabetes: HgbA1c done past year

Diabetes: Adequate control

Diabetes: Cholesterol measures

Diabetes: Cholesterol controlled

Diabetes: Eye Exam

Diabetes: Renal Exam

Hypertension: BP <= 140/90

Flu shot (over 65)

Pneumococcal vaccine (over 65)

Mental health followup after discharge

Before

After

Data Source: Thomson TG, Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Washington, DC: US Department of Health and Human Services; 2004.

Physicians Recognize Value of EMRPhysicians Recognize Value of EMR

1DesRoches CM et al. N Engl J Med 2008;359:50-60

•EMR viewed as part of the answer but adoption stuck at 4% for full functionality (13% basic functionality)1

✓

✓

✓

✓

✓

Positive SurveyResponses

9

EHR Functionality Use by Practice SizeEHR Functionality Use by Practice Size

Use of the following: prescription orders, lab orders and viewing, radiology tests and results viewing and clinical notes

Source: MGH Institute for Health Policy, George Washington University and RTI, A National Survey of Health Record Keeping among Physicians & Group Practices in the United States, Preliminary Data

Major Barriers to EHR AdoptionMajor Barriers to EHR Adoption

Percent of physicians reporting a “major barrier”

Source: MGH Institute for Health Policy, George Washington University and RTI, A National Survey of Health Record Keeping among Physicians & Group Practices in the United States, Preliminary Data

How Does HIT Save Money? How Does HIT Save Money?

EHR Effects Completeness, correctness, decision support, formulary, brand to generic,

duplicate/redundant meds and tests, charge display Workflow support, messaging (pt/provider), referral, A/R, team

CPOE Effects Reduction in hospitalization/LOS due to ADEs, clinical decision support

HIEI Effects Reduction in unnecessary and redundant tests and procedures Labor cost savings

Telehealth Effects Reduction in patient transport, utilization of hospitals, and physician office visits

PHR Effects Administrative time savings Reduction in hospitalizations and physician visit utilization Improved medication safety Reduction in redundant laboratory tests

www.citl.org

CITL HIT Value AssessmentsCITL HIT Value Assessments

Net US could save $150B with HIT adoption, or approximately 7.5% or US Healthcare Expenditure The Value of Ambulatory Computerized Order Entry (ACPOE)

$44B US nationally; $29K per provider, per year

The Value of HealthCare Information Exchange and Interoperability (HIEI) $78B/yr

The Value of IT-enabled Chronic Diabetes Management (ITDM) $8.3B Disease Registries; Advanced EHR $17B

The Value of Physician-Physician Tele-healthcare >$20B*

The Value of Personal Health Records Approx. $20B

www.citl.org • CITL: 89% of the benefit of EMR adoption does not go to Providers1

2Middleton B. Health Aff (Millwood). 2005;24(5):1269-72.

A public-private “Community” was established to serve as A public-private “Community” was established to serve as

the focal point for America’s health information concerns the focal point for America’s health information concerns and drive opportunities for increasing interoperabilityand drive opportunities for increasing interoperability

Healthcare Information Technology

Standards Panel (HITSP)

Nationwide Health Information

Network Architecture Projects (NHIN)

The Health Information Security & Privacy

Collaboration (HISPC)

Certification Commission

for Healthcare Information Technology

(CCHIT)

American Health

Information Community(AHIC 2.0)

The Community is a federally-chartered commission and will provide input and recommendations to HHS on how to make health records digital and

interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way.

The Community is a federally-chartered commission and will provide input and recommendations to HHS on how to make health records digital and

interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way.

CongressNCVHS

NGA

HIMSS

AMIA

AHIMA

Clinical/Professional Societies

Advocacy Groups

State Leg.

VendorGroups

What are Policy Options to Stimulate What are Policy Options to Stimulate HIT?HIT?

Standards acceleration/harmonization, certification HITSP, CCHIT

Incentives for adoption (CMS pilot) Grants and loans, tax credits, other subsidies Reimbursement incentive

NHIN re-usable technologies ONC NHIN demos

Clinical decision support knowledge repository AHRQ

IT Workforce training AMIA 10x10, HIMSS

HIT comparative effectiveness research AHRQ, ONC, NLM