Health Information Technology Citizen

1
Health Information TechnologyCitizens Health
Care Working Group

• Presented by
• Scott D. Williams, M.D., M.P.H.
• Vice-President, HealthInsight
• July 22, 2005

2
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

3
Issues in Health IT

• Technology
• Architecture
• Hardware/ Software
• Connections
• Support
• Governance
• Community interests
• Privacy, security
• Resource allocation

• Value
• Who benefits who pays?
• Efficiency
• Outcomes
• Standards
• Self-regulated
• Externally- regulated
• Market driven

4
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

5
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 lt 1/ claim
• Provider value
• Faster payments
• Fewer rejected claims
• Less staff time

6
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

7
Value EMRs
EMR Adoption Physician Offices
17 Hospital ER 31 Hospital
Outpatient 29 CDC March 2005
HIMSS, September 2004
8
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

ms mean score Massachusetts Medical Society
Survey Spring 2003
9
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

10
Value EMR Business Case for the Physician
Mean Benefit Low End High End
Savings (paperless, capitated 17, Fee for service 83) 50,300 21,800 85,600
Costs, Year 1 (hardware, software, inefficiency, licenses, support, updates) 22,100 13,700 36,000
Costs, Year 2 5,300 2,600 9,500
Total ROI, Year 1 28,200 8,000 49,600
Total ROI, Year 2 45,000 19,000 76,100
Wang, S.J. et al. 2003
11
Value EMR Business Case for the Physician
Wenner Georgia HIMSS Dec 2002
12
Value EMR Business Case for the Physician
Wenner Georgia HIMSS Dec 2002
13
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

14
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
15
RHIOs Wiring Healthcare Efficiently
Current system fragments patient information and
creates redundant, inefficient efforts
Source Indiana Health Information Exchange
16
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
17
Value Level 4 HIE

• Contributions to the 94.3 billion benefit
  Service categories
• Contributions to the 16.5 billion cost

Laboratory testing 31.8 billion
Imaging 26.2 billion
Provider-payer transactions 20.1 billion
Chart transfers between providers 13.2 billion
Pharmacy 2.71 billion
Public health reporting 195 million
Clinical office system cost 9.08 billion
Hospital system cost 1.58 billion
Provider interface cost 5.40 billion
Stakeholder interface cost 467 million
Walker et al. Health Affairs. January 2005
18
Value Level 4 HIE

• Where does 77.8 billion net value accrue (HIE
  Only)?

Providers 33.7 billion
Payers 27.6 billion
Laboratories 13.1 billion
Radiology centers 8.2 billion
Pharmacies 1.3 billion
Public health departments 94 million
Walker et al. Health Affairs. January 2005
19
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
20
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

21
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
22
Value CDSS

• CPOE
• 25 improvement in ordering of corollary
  medications by faculty and residents (plt0.0001)
  Overhage, 1997
• 55 decrease in non-intercepted serious
  medication errors (p0.01) Bates, 1999
• 81 decrease in medication errors (plt0.0001)
  Bates, 1999
• Improvement in 5 prescribing practices (plt0.001)
  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
  (plt0.001) Evans 1994
• 70 decrease in adverse drug events caused by
  anti-infectives (p0.02) Evans 1998

Source Center for Information Technology
Leadership, 2003
23
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
24
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
25
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
26
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
  dont encumber interstate health data exchange
• Incentivize health IT savings to be redirected
  into effective health care interventions