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Health Information Technology Citizen’s Health Care Working Group. Presented by Scott D. Williams, M.D., M.P.H. Vice-President, HealthInsight July 22, 2005. Overview. HealthInsight Medicare Quality Improvement Organization (QIO) with CMS contract for Utah and Nevada DOQ-IT Project Pilot

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health information technology citizen s health care working group

Health Information TechnologyCitizen’s Health Care Working Group

Presented by

Scott D. Williams, M.D., M.P.H.

Vice-President, HealthInsight

July 22, 2005

overview
Overview
  • HealthInsight
    • Medicare Quality Improvement Organization (QIO) with CMS contract for Utah and Nevada
    • DOQ-IT Project Pilot
      • Promoting the use of Electronic Medical Records in small and medium primary care physician offices
  • Utah Health Information Network (UHIN)
    • 12 years of successful administrative health data exchange
      • Claims, remittance, eligibility
      • Credentialing, coordination of benefits, EFT
    • Regional Health Information Organization development grantee (AHRQ)
      • Labs, pharmacy, clinical notes and reports
issues in health it
Technology

Architecture

Hardware/ Software

Connections

Support

Governance

Community interests

Privacy, security

Resource allocation

Issues in Health IT
  • Value
    • Who benefits & who pays?
      • Efficiency
      • Outcomes
  • Standards
    • Self-regulated
    • Externally- regulated
    • Market driven
health it applications
Health IT: Applications
  • Electronic Medical Record (EMR)
    • Paperless office
    • Personal Health Record
  • Health Information Exchange (HIE)
    • Regional Health Information Org. (RHIO)
    • Allows interoperability between stakeholders
  • Clinical Decision Support Systems (CDSS)
    • Case and cohort management
    • Computerized Physician Order Entry (CPOE)
    • Prompts, recalls, trends, protocols, drug interactions, generics, performance measures
value administrative health data
Value: Administrative Health Data
  • UHIN (17 million claims/year)
    • Efficiency of Claims Processing by 1 adjudicator
      • Paper 100-150/ day
      • Scanned 300/ day
      • EDI 700-800/ day
      • Autoprocessing 60% of claims require no human involvement
    • Payer value- just for intake of claim
      • Paper = $6-10/ claim
      • EDI < $1/ claim
    • Provider value
      • Faster payments
      • Fewer rejected claims
      • Less staff time
lessons learned uhin
Lessons Learned: UHIN
  • Champion- credible, neutral, trusted
  • Value accrues to all participants
    • Drives priorities
    • Drives business model
  • Community ownership & governance
    • Consensus decision making
  • Standards driven
  • Use of data subject to governance process
value emrs
Value: EMRs

EMR Adoption

Physician Offices 17%

Hospital ER 31%

Hospital Outpatient 29%

CDC March 2005

HIMSS, September 2004

value emr adoption barriers among physicians
Initial Capital Cost (345/423, ms = 1.85)

Time Cost (323/423, ms = 2.74)

Confidentiality and Security Concerns (181/423, ms = 2.93)

Maintenance cost (300/423, ms = 3.00)

Interfere with doctor-patient communication

Concerns about learning new technology

Lack of technical support

Lack of control over decision

Lack of perceived benefits

Value: EMR Adoption Barriers among Physicians

ms = mean score

Massachusetts Medical Society Survey Spring 2003

value emr business case for the physician
Value: EMR Business Case for the Physician
  • Process efficiency (requires workflow redesign)
    • Transcription
    • Forms
    • Telephone calls
    • Information collection from patients
  • Lower overhead
    • Fewer FTEs
    • Less space needed for charts
  • Increased reimbursement
    • Better coding & recovery
    • More patients seen (if workflow changes)
    • Pay for Performance
value emr business case for the physician2
Value: EMR Business Case for the Physician

Wenner Georgia HIMSS Dec 2002

value emr business case for the physician3
Value: EMR Business Case for the Physician

Wenner Georgia HIMSS Dec 2002

value hie
Value: HIE
  • Automation of clinical processes
  • More timely, complete, accurate patient information at point of service
  • Efficiency of connectivity
  • Facilitate clinical decision support systems across communities
value hie1
Value: HIE
  • Missing Patient Data
    • 13.6% of primary care physician visits
    • 52% of missing data resides outside of system
    • 44% of data somewhat likely to adversely affect patients
    • 60% of data likely to delay care or result in additional services
    • More likely among recent immigrants, new patients, those with complex medical problems
    • Less likely where physician has full EMR and also in rural areas

Smith et al. JAMA. February 2005

slide15

RHIOs: “Wiring” Healthcare Efficiently

Future system will consolidate information and provide a foundation for unifying efforts

Hospitals

Public health

Hospitals

Public health

Primary care physician

Laboratory

Primary care physician

Laboratory

Health

Information

Exchange

Pharmacy

Pharmacy

Specialty physician

Specialty physician

Payors

Payors

Ambulatory center (e.g. imaging centers)

Ambulatory center (e.g. imaging centers)

Current system fragments patient information and creates redundant, inefficient efforts

Source: Indiana Health Information Exchange

value hie2
Value: HIE
  • Based on published data and expert opinion
  • Interoperability
    • Level 2 = Fax
    • Level 3 = Machine-organizable data
    • Level 4 = Machine-interpretable data
  • Net Value after full implementation
    • Level 2 = $21.6 billion /year
    • Level 3 = $23.9 billion/ year
    • Level 4 = $77.8 billion/ year
  • Costs: Benefit Calculation for Level 4
    • Years 1-10 = $276 billion: $613 billion = $338 billion
    • Year 11 + = $16.5 billion: $94.3 billion = $77.8 billion

Walker et al. Health Affairs. January 2005

value level 4 hie
Value: Level 4 HIE
  • Contributions to the $94.3 billion benefit: Service categories
  • Contributions to the $16.5 billion cost

Walker et al. Health Affairs. January 2005

value level 4 hie1
Value: Level 4 HIE
  • Where does $77.8 billion net value accrue (HIE Only)?

Walker et al. Health Affairs. January 2005

value level 4 hie2
Value: Level 4 HIE
  • 50-200 Bed Hospital
    • $2.7 million in IT investment
    • $250,000/year in maintenance
    • $1.3 million/year in transaction savings
      • $570,000 from other providers
      • $200,000 from other laboratories
      • $170,000 from radiology centers
      • $250,000 from payers
      • $70,000 from pharmacies

Walker et al. Health Affairs. January 2005

hie uhin approach
HIE: UHIN Approach
  • Identify value-based priority use cases with interested stakeholders
  • Obtain broader stakeholder support
  • Develop and adopt technical model
  • Develop and adopt financing model
  • Convene standards development process
  • Adopt standards
  • Pilot, refine, implement
value cdss
Value: CDSS

“...risk-adjusted cost varied almost 3-fold...”

Duke Clinical Research Institute 2002

Practice Variation

“...cost of poor quality was...nearly 30% of the expense base...core medical processes that comprise the majority of what we do”

Mayo Clinic

“...72% drop in mean respiratory costs...”

APAM 2000

30%

“...27% difference in cost of treating otitis media...”

Ozcan 1998

“...20 to 30% of the acute and chronic care that is provided today is not clinically necessary...”

Becher, Chause 2001

70%

“...The cost of poor quality in health care is as much as 60% of costs...”

Brent James, M.D., IHC.

Project Hope, Wennberg et.al., 2003/HealthAlliant

“...30% of direct health care outlays are the result of poor-quality care...”

MBGH, Juran, et al 2002

Annual U.S. health care expenditures: $1.7 trillion x 30% = ~ $500 billion

value cdss1
CPOE

25% improvement in ordering of corollary medications by faculty and residents (p<0.0001) Overhage, 1997

55% decrease in non-intercepted serious medication errors (p=0.01) Bates, 1999

81% decrease in medication errors (p<0.0001) Bates, 1999

Improvement in 5 prescribing practices (p<0.001) Teich, 2000

CDSS

6 of 14 studies showed improvement in patient outcomes. Hunt 1998

43 of 65 studies showed improvement in physician performance. Hunt 1998

17% improvement in antibiotic regimen suggested by computer consultant versus physicians (p<0.001) Evans 1994

70% decrease in adverse drug events caused by anti-infectives (p=0.02) Evans 1998

Value: CDSS

Source: Center for Information Technology Leadership, 2003

value cdss2
Value: CDSS

100%

Medical Knowledge

Treatment

50% of Cost

20% of Return

Diagnostic

Redundancy

Patient Data

Errors

EMR

HIE

CDSS

Source: SBCCDE, CITL, Gordian Project analysis

value outpatient cpoe
Value: Outpatient CPOE
  • Savings from nationwide adoption
    • Adverse Drug Reactions = $2 billion
      • Eliminate 2 million adverse drug reactions
      • Eliminate 190,000 hospitalizations
    • Medication management = $27 billion
    • Radiology management = $10.4 billion
    • Laboratory management = $4.7 billion
    • Total = $44 billion

Source: Center for Information Technology Leadership, 2003

value who benefits who pays
Value: Who benefits? Who Pays?

Private Payers

Medicare

Medicaid

Self-insured

Self-pay

Physicians

Ambulatory Computer-based Physician Order Entry

Source: Center for Information Technology Leadership, 2003

health it federal government roles
Health IT: Federal Government Roles
  • Facilitate the implementation of a national strategy
  • Support innovation experiments
  • Confirm business value and align incentives
  • Coordinate the implementation strategies of federal health care agencies
  • Assure the rapid development of data and technical standards with broad input
  • Assure that privacy and security regulations don’t encumber interstate health data exchange
  • Incentivize health IT savings to be redirected into effective health care interventions