Statewide Implementation of EHRs and the Massachusetts e-Health Collaborative

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Statewide Implementation of EHRs and the
Massachusetts e-Health Collaborative

• David Bates, MD, MSc
• Chief, Division of General Internal Medicine,
  Brigham and Womens Hospital,
• Chair, National Alliance for Primary Care
  Informatics

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Overview

• Benefits of EHRs
• Current state of adoption of EHRs
• History of MaEHC
• Plans of MaEHC

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Key Domains of Benefit

• Availability
• Communication
• Operational savings
• Decision support
• Reducing errors
• Improving guideline compliance
• Reducing costs
• Quality measurement
• Satisfaction
• Efficiency

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Costs of EHR vs. Benefits
Wang et al, Am J Med 2003
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Quality and Safety Impact

• Safety
• Lots of room for improvement
• Quality
• Probably even more room than with safety

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Computerisation in UK FP

• 70 practitioners are not computerised
• 95 of all prescriptions are produced
  electronically from clinical information systems
• Nearly ready to transfer the record between
  systems with semantic integrity

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Australian Experience

• Very high levels of use
• Most providers use one EHR (although other
  options available)
• Paid for through pharmaceutical advertising
• When providers prescribe see diagnosis-specific
  ads
• Relatively little decision support so far

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U.S. Picture EHRs Finally Getting National
Attention!

• By computerizing health records, we can avoid
  dangerous medical mistakes, reduce costs, and
  improve care.
• George W. Bush, State of the Union
• 1/2004

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Single Individual in HHS for HIT

• David Brailer named to role on 5/5/04 by Secty
  Thompson
• Also announcement that remainder of CHI standards
  have been adopted
• Need for more federal support

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NAPCI Vision Statement

• Every primary care provider will use information
  technology that includes electronic health
  records with the ability to access and
  communicate needed clinical information to
  achieve high quality, safe, and affordable health
  care.

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NAPCI Members

• AAPAmerican Academy of Pediatrics
• ACPAmerican College of Physicians
• AMIAAmerican Medical Informatics Assn
• ANAAmerican Nursing Association
• NAPCRGNorth American Primary Care Research Group
• NONPFNational Organization of Nurse Care
  Research
• SGIMSociety of General Internal Medicine
• STFMSociety of Teachers of Family Medicine

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Current State of EHR Adoption

• Most physicians do not currently use the
  technology
• ? 15 in Massachusetts
• Large groups are rapidly adopting
• Small groups are not
• Market failure
• Providers make investment
• Payers/purchasers realize most of the benefits

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EHR Use at Partners
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Misaligned Incentives
Providers
Others
Ambulatory Computer-based Provider Order Entry
Source Center for Information Technology
Leadership, 2003
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Physician Perspectives Recent MMS Survey Data

• Physician Attitudes
• 84 agree that computers improve quality  
• 78 think computers have beneficial effect on
  interactions within the health care team
• Attitudes vs. Intentions
• 85 believe doctors should computerize writing
  prescriptions, yet 49 do not intend to do so  
• 89 believe doctors should computerize recording
  patient summaries, yet 48.5 do not intend to do
  so
• 83 believe doctors should computerize recording
  treatment records, yet 48.7 do not intend to do
  so

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Top Reasons for Disconnect

• Initial capital cost
• Time cost
• Breach of confidentiality or lacking security
• Maintenance costs

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Barriers to EHR Adoption

• Economic barriers
• High initial financial costs
• Slow and uncertain financial payoffs
• High initial physician time costs
• Lack of financial incentives
• Underlying barriers (system and culture)
• Difficulties with technology
• Complementary changes and support
• Inadequate electronic data exchange
• Negative physicians' attitudes

Miller and Sim, Health Affairs 2004
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The MassachusettseHealth Collaborative

• Expanding Electronic Health Record Use and
  Building a Statewide Health Information
  Infrastructure in Massachusetts

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The MassachusettseHealth Collaborative

• Goal To improve the safety and quality of
  patient care in every ambulatory provider office
  in Massachusetts
• Approach Develop partnership among key
  stakeholders to effect widespread adoption of
  electronic health records and the establishment
  of health information infrastructure

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Specific Goals

• Build a stakeholder coalition
• Identify preferred vendors of computer hardware
  and software
• Identify and recruit internists and physician
  groups
• Assist providers in acquisition and
  implementation through financial, educational,
  and support programs
• Develop infrastructure for data exchange

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Key Stakeholders

• Providers
• Purchasers
• Payors
• Vendors
• Software
• Hardware
• Malpractice insurers
• Patients

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Key Alliances and Resources

• Governor Romney/administration
• Mass ACP
• Massachusetts Medical Society
• Department of Health and Human Services
• Massachusetts legislature/Harriet Chandler
• Mass Health Data Consortium/MassShare

• Massachusetts Coalition for Prevention of Medical
  Error
• Major insurers
• Malpractice carriers (ProMutual, CRICO)
• Large purchasersGE, IBM/Leapfrog
• National Alliance for Primary Care Informatics
• MassPro

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Current Status

• Not-for-profit corporation (9/28/04)
• Governance shared among stakeholders
• CEO Selected - Micky Tripathi
• COO Selected Robert Mandel, MD
• Formal kickoff in fall 2004
• Pilot implementation in 3 communities spring
  2005
• Competitive application/selection process
• Phase I proposals received Jan 21
• 35 received

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Finalist Communities
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Scope and Timing of Pilot Projects

• Universal (gt75) adoption of office-based
  electronic health records
• Establishment of functional exchange of health
  information (e.g., laboratory results) among
  health care providers acute care hospital
  within each community
• Implementation over 12 months
• Evaluation in parallel and ongoing

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Goals of Pilot Projects

• Knowledge and experience that will enable the
  statewide implementation of EHRs and the
  establishment of a statewide health information
  infrastructure
• Information/knowledge in 6 domains

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Goals of Pilot Projects (contd)

• 1. Economic
• Costs of implementation
• Resources necessary for incentive program
• Savings
• Physician productivity
• 2. Quality/Safety/Service
• HEDIS measures
• Pharmacy use
• Satisfaction

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Goals of Pilot Projects (contd)

• 3. Adoption Barriers
• 4. Implementation/Tactics
• Vendors
• Providers
• Interoperability/functionality
• 5. Role of Employers
• 6. Role of Payers

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AHRQ Grant - Statewide Implementation of EHRs

• David Bates, Steven Simon, Rainu Kaushal, Eric
  Poon, Lynn Volk
• Designed prior to full evolution of the MAeHC -
  will modify some
• (David Bates also heading up the MAeHC evaluation
  working group so will be additional efforts)

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Specific Aims

• Evaluate effectiveness of program to promote EHR
  adoption in Mass
• Evaluate effect on med errors
• Evaluate effect on quality of care
• Evaluate effect of academic detailing
  intervention on enhancing successful EHR adoption

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Specific Aims (contd)

• Evaluate the degree and correlates of physician
  receptivity to EHRs
• Evaluate effects of program on physician
  receptivity and EHR use
• Measure potential facilitators of physicians
  adoption of EHRs

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Methods

• Office practice survey
• Medication error study using duplicate
  prescription pads/EHRs
• HEDIS measures comparison
• Physician other provider surveys
• RCT of academic detailing

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Additional Areas to Evaluate

• What are the implementation costs in terms of hw,
  sw, training and lost productivity that may be
  considered in designing incentive programs?
• What is the programs impact on
• Physician office savings (eg, transcription)?
• Medical cost savings (eg, drug util, lab util)?

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Summary

• EHRs and HII will lead to large, measurable
  improvements in quality and safety
• Formidable barriers exist
• Timing of when benefits accrue uncertain
• Statewide collaborative effort is off and running
  to address these barriers
• Massachusetts is a national leader
• Longer run, financial incentives will be key

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