Optimizing Value from the EMR

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Optimizing Value from the EMR 3rd Annual
Rhode Island Health IT Fair March 3,
2007 Peter Basch, MD Medical Director,
eHealth MedStar Health
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My perspective

• Practicing physician early adopter of HIT
• Medical Director eHealth, MedStar Health
• Mid-Atlantics largest healthcare system
• 7-hospital, not-for-profit
• 150,000 inpatient admissions annually
• 1 million outpatient visits annually
• Overall leadership for our ambulatory EMR
  initiative
• Chair, Maryland Task Force on EHRs
• Co-Chair, Physicians EHR Coalition
• Board member, MD-DC Collaborative for HIT
• Board member and Leadership Council member,
  eHealth Initiative
• (Views expressed today are mine and not
  necessarily those of any of the organizations
  listed above)

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Washington Primary Care Physicians

• 1995
• 4-person internal medicine
• Two offices
• Washington, DC
• Maryland
• 12 support staff
• Drowning in paper
• Struggling to survive with declining
  reimbursements / increasing responsibilities

• Buy an EMR
• Sell ourselves to a hospital

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Washington Primary Care Physicians

• 1995
• 4-person internal medicine
• Two offices
• Washington, DC
• Maryland
• 12 support staff
• Drowning in paper
• Struggling to survive with declining
  reimbursements / increasing responsibilities

• 2007
• 7-person internal medicine
• One office
• Washington, DC
• 12 support staff
• Drowning in information
• Surviving all enabled by an EMR

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Value for front desk staff

• Never having to get up to pull a chart for a
  patient visit or phone call
• Being able to answer simple questions, such as
  when was my last tetanus booster? without
  having to take a message, find the chart, ask the
  doctor, and then call the patient back.
• Never using a sticky note again
• Being able to send a message/query to multiple
  staff members/clinicians simultaneously
• Being able to easily document all actions taken
  (such as the name of the pharmacist you just
  spoke with, along with a date/time stamp)

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Value for medical assistants

• Never using scrap paper again to write down vital
  signs
• Being able to actually answer patient questions
  such as how is my weight doing?
• Being able to actually answer pharmacist
  questions about details on current prescriptions,
  prior prescriptions, and refill history

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Value for management

• Being able to easily respond to and manage
  drug/vaccine recalls
• Being able to create and easily administer
  specific quality goals such as maintaining a
  problem list with specified goals
• Being able to easily manage administrative
  compliance goals such as timeliness of signed
  progress notes, return of phone calls, etc.
• Being able to easily participate in research
  protocols

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Value for physicians

• Being able to easily accommodate patients who are
  on multiple medications and need one set of
  prescriptions for the drug store, and a duplicate
  set for mail-order
• Being able to verify appropriateness of coding
  decisions
• Being able to view and act upon CDS prompts for a
  particular condition (way beyond what my memory
  would permit)
• Being able to view care management for specific
  conditions over time
• Being able to have access to the full record,
  anytime, anywhere
• Remarks from my partners at go-live, 3 months, 6
  months

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Remarks from my partners go-live
I hope you know what you are doing!
I did tell you that Ive never used a computer
before didnt I?
Remind me, whos paying for this?
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Remarks from my partners 3 months
What am I, a f_at_ing secretary?
I understand the keyboard, but whats the mouse
for?
I really need to learn to type!
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Remarks from my partners 6 months
Dont you dare I couldnt survive without it
We can never go back to paper!
Remind me, whos paying for this?
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The long and painful road to EMR

• New skills
• Computers / Typing
• New workflows
• Unlink MA MD
• Flow of office visits
• New opportunities
• Expanding CDS
• Use of registries
• Including eCare
• MD Backlash
• More documentation
• More work

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Financial ROI for my practice

• Costs
• Software
• Hardware
• Networking
• 200K
• Support
• 10K/yr ???
• Lost productivity
• My time
• Total over 10 years
• 500K ???

• Return
• Increased revenue
• No increased productivity
• Lucked into a P4P demo
• 300K
• Decreased costs
• Eliminated transcription
• 300K
• No new charts
• 30K
• Decreased staffing
• 1M
• Bottom line 1M

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What does the literature say about ROI?

• Wang, 2003 Am Journal of Medicine
• Mixed financial ROI primarily to plans
• Connecting for Health 11/04
• Negative ROI for small practices (20K/MD/yr)
• C!TL Report on The Value of HIEI (2/05)
• Positive ROI of 75K/MD/yr
• Miller, 2005 Health Affairs
• Positive ROI of 34K/MD/yr
• Reduced or eliminated transcription
• Reduced staffing
• Right coding

Positive ROI of 15-20K/MD/yr
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What does this mean for your practice?

• Productivity
• Will likely see a temporary ?
• Will likely not see any long-term ?
• Staffing
• May see a reduction
• Only if staffing starts out fat
• Staff dont fire themselves
• Transcription
• Need to develop good templates
• Or substitute voice recognition
• Only valid if using transcription now
• Chart pulls
• Only if you currently pay for chart pulls

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Can the EMR benefit physicians?

• Absolutely!
• Once thru the pain, can lead to a better / more
  satisfying practice
• Will likely produce a financial ROI
• However, somethings missing
• Dark finding from the Miller study was that
  EMRs are adoptable, affordable, perhaps even
  profitable but not being used for quality /
  value enhancement

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The EMR and quality improvement

• No correlation between EMR use and improved
  outcomes in diabetes
• (OConnor, PJ et al., Ann Fam Med, 2004)
• No improvement in lipid management after 5 years
  of using an advanced EMR
• (Siemienczuk, J et al, Am J of Managed Care, 2004)

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Can the EMR benefit physicians?

• Absolutely!
• Once thru the pain, can lead to a better / more
  satisfying practice
• Will likely produce a financial ROI
• Note that I have only presented value for MDs and
  staff and ignored value for patients, payers,
  purchasers, society
• Dark finding from the Miller study was that
  EMRs are adoptable, affordable, perhaps even
  profitable but not being used for quality /
  value enhancement
• Dark finding discussed by Sidorov in Health
  Affairs (8/06)

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What does it mean if successful EMR adoption has
led to

• a financial benefit to physicians and limited
  (or no) value for patients?
• IMHO (and hopefully yours)
• We have succeeded in digitizing dysfunction
• Our patients deserve better!
• IT is not worth the time and effort
• Were we dead wrong about ITs potential?
• Or, is whats in IT for me the wrong question?

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Wrong answer? Wrong question?
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The long and painful road to EMR

• New skills
• Computers / Typing
• New workflows
• Unlink MA MD
• Flow of office visits
• New opportunities
• Expanding CDS
• Use of registries
• Including eCare
• MD Backlash
• More documentation
• More work

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Healthcare transformation enabled by the EMR

• New skills
• Computers / Typing
• New workflows
• Unlink MA MD
• Flow of office visits
• New opportunities
• Expanding CDS
• Use of registries
• Including eCare
• MD Backlash
• More documentation
• More work

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Healthcare transformation enabled by the EMR

• Vision
• Practice redesign
• Reimbursement reform
• Advanced EMR

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Quality failures of EMR implementations

• Vision
• Practice redesign
• Reimbursement reform
• Advanced EMR

• Miller
• Sidorov
• OConnor
• Siemienczuk
• Studied implementations with (at best) only one
  of the four necessary components

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Quality success of EMR implementation

• Vision
• Practice redesign
• Reimbursement reform
• Advanced EMR

• Miller Health Affairs (1/07) EMRs in
  Community Health Clinics
• Adopted / optimally used
• Produced obvious / quantifiable improvements in
  quality
• Lost money

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Vision

• IOMs STEEEP care
• Safer / Timely / Effective / Equitable /
  Efficient / Patient-centric
• Improving value (benefit / cost)
• Reducing overuse / underuse / misuse / waste
• Have EMR use produce measurably better care
• Quality / safety / risk reduction

• Based on societal needs
• Achievable
• Crafted by multiple stakeholders
• Must not alienate patients / doctors

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Practice redesign

• Informing care
• Improving reactive care
• Decreasing time from bench-to-bedside
• Transforming care
• Including proactive care
• Including eCare
• Including self-care
• Using enhanced communication as a tool to
  improve care

• Operationalize vision (not just EMR adoption)
• Improve quality
• Improve effectiveness
• Improve efficiency
• Makes sense
• Doable

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Reimbursement reform

• Improving payment for cognitive services
• Creating payment for
• Proactive care
• Population management
• Chronic care
• Care coordination
• eCare
• Collaborating in self-care
• Medical home
• ? P4P

• Current payment system
• Procedures reimbursed relatively generously
• Visits reimbursed poorly
• Non-visit based care / management not reimbursed
  at all
• The EMR primarily increases value of visits and
  non-visit care / management
• The more the EMR is optimally used, the more
  negative the ROI

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Progress in last 5 yrs ? risks of EMR investment
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Advanced EMR next steps

• Prompts and alerts
• Reactive and proactive care
• Care coordination
• Prescribing / Referring linking to effectiveness
• Registry fed by clinical data
• Allows for proactive care
• Population management
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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What is the current state of embedded CDS?

• Most EMRs dont have advanced CDS
• That is changing
• CCHIT requirements will help to drive more and
  better CDS
• Nevertheless, where CDS exists it remains
  underused / ignored
• Alert fatigue
• Too many, too far in background
• Not granular, not actionable
• Alert irrelevance

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Improving CDS actionability
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Population management from within the EMR
integrated registries

• The problem with health plan registries
• Integrated clinical registries
• Staff use
• Physician use

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Integrated eCare

• Current model of eCare
• Future model
• Reactive
• Asynchronous
• Synchronous
• Proactive
• As a tool for population management
• As a tool for care coordination

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Questions to the audience

• If appropriate reimbursement were provided
• What of your OVs could be done using eCare?
• What could you do prospectively with your chronic
  disease patients?
• And if appropriate P4P were available
• How would you improve preventive services
  adherence?
• How would you improve (or start) care
  coordination?
• How would you improve (or start) more active
  collaborations with your patients?
• What would it take to get you to do less / manage
  more?

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The Greenfield Clinic Story
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Optimizing value from the EMR

• More than
• IT adoption
• Generating a ROI
• Reclaiming the high road creating a path for
  improving medical care using the infrastructure
  of HIT
• Vision Practice redesign Reimbursement reform
  Advanced EMR
• This is doable today!

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But before you think Ive gone off the deep-end
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Advanced EMR next steps

• Prompts and alerts
• Reactive and proactive care
• Care coordination
• Prescribing / Referring linking to effectiveness
• Registry fed by clinical data
• Allows for proactive care
• Population management
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Reactive and proactive care
• Care coordination
• Prescribing / Referring linking to effectiveness
• Registry fed by clinical data
• Allows for proactive care
• Population management
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Who owns the CDS?
• Used against us in lawsuits?
• Prescribing / Referring linking to effectiveness
• Registry fed by clinical data
• Allows for proactive care
• Population management
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Who owns the CDS?
• Used against us in lawsuits?
• Prescribing / Referring ? burden of prior
  auth
• Registry fed by clinical data
• Allows for proactive care
• Population management
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Who owns the CDS?
• Used against us in lawsuits?
• Prescribing / Referring ? burden of prior
  auth
• Registry fed by clinical data
• Others clamoring to own this
• No reimbursement model
• eCare to include reactive and proactive model
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Who owns the CDS?
• Used against us in lawsuits?
• Prescribing / Referring ? burden of prior
  auth
• Registry fed by clinical data
• Others clamoring to own this
• No reimbursement model
• eCare reimbursement has never gone beyond pilots
• Appropriate sharing of data enables better care
  collaborations

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Advanced EMR next threats

• Prompts and alerts
• Who owns the CDS?
• Used against us in lawsuits?
• Prescribing / Referring ? burden of prior
  auth
• Registry fed by clinical data
• Others clamoring to own this
• No reimbursement model
• eCare reimbursement has never gone beyond pilots
• Appropriate sharing of data may also enable care
  confusion and information overload

• Embedded CDS
• Integrated ePrescribing
• Integrated eReferrals
• Integrated registry
• Integrated eCare
• Linked Patient Portal / PHR

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Lets not ignore the obvious

• We cant do this alone!
• MD adoption of HIT will not fix what is broken
  with healthcare
• David Brailer said it will take another 5-10
  years!
• Sustainable business case for information
  management / quality
• Appropriate reimbursement
• Not IT subsidies
• Decrease in process frictions
• Pointless prior authorizations
• Wasteful documentation rules

How long has that been here?
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Rhode Island MDs are well positioned to optimize
value from the EMR
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Questions

• peter.basch_at_medstar.net