October 25, 2005

1
Realizing the Financial Benefits of Electronic
Health Records What do the Data Show?The VA
Experience

• October 25, 2005
• Robert M. Kolodner, MDChief Health Informatics
  Officer, VHADepartment of Veterans Affairs

2
Cost Savings and EHRs in VA

• 20 year history of computer use to support care
  in the Veterans Health Administration (VHA)
• Sometimes challenging to tease out effects of
  the Electronic Health Record from other major
  changes in VHA, especially since 1995
• Shift from Inpatient to Outpatient care
• Reorganization to 22 (now 21) regional networks
• Implementation of performance measures
• Shift from facility-centric to veteran-centric

3
Transformational Strategies for VA Health Care

• In summary, electronic health records,
  performance management, and a patient-centric
  focus have been critical transformational
  strategies for the VA. They have been utilized to
  support achievement and are associated with
  measurable progress in each of the VAs value
  domains.
• The American Journal of Managed Care, November
  2004

4
2005 Who is VHA . . . Veterans Health
Administration

• 5.2 million patients, 7.6 million enrollees
• 30 Billion budget
• 1,300 Sites-of-Care
• Including 171 medical centers or hospitals
• 870 clinics
• 207 counseling centers
• long-term care programs
• 197,500 Employees (14,000 MD , 56,000 Nurses,
  33,000 AHP)
• 150,000 volunteers
• Affiliations with 107 Academic Health Systems
• 1,500 Health Professions Training Affiliations
• Additional 25,000 affiliated MDs 35,000
  residents fellows in 14,000 slots
• 89,000 trainees in all disciplines
• Nearly half US health professionals (gt65 MDs)
  have some training in VA
• 1.7B Research Rehabilitation, Health
  Services, Clinical, Basic

5
VAs Health Information System is VistA

• CPRS is the integrated EHR application
• VA runs 128 VistA systems these sites
• Down from 172 VistA systems 10 years ago
• 180,000 PCs and thin clients
• Delivers a complete hospital information system,
  electronic health record, imaging, Bar Code
  Medication Administration
• Hardware, software, maintenance, upgrades,
  staffing
• For FY2004
• Cost per enrollee
• 78 / enrollee
• Average cost per hospital (n158)
• 3.6 million

6
And VistA Is Actively Used... Some National
VistA Statistics (TotalDaily)

• Documents (Progress Notes, Discharge Summaries,
  Reports)
• 742,000,000.. 576,000 each workday
• Orders
• 1.48 Billion.... 922,000 each workday
• Images
• 385,000,000 587,000 each workday
• Vital Sign Measurements
• 915,000,000 676,000 each workday
• Medications Administeredwith the Bar Code
  Medication Administration (BCMA) system
• 716,000,000 607,000 each workday

Statistics as of September 2005
7
VistA Data Trend Rate of Increase
8
Financial Benefits of EHR in VA

• Unable to provide overall benefits for the system
  since DHCP/VistA implemented and matured over 20
  years and baselines were not taken
• HOWEVER
• Many local examples with costs
• Some local examples with implications without
  exact costs
• Some speculations
• not counting savings by not repeating tests / or
  avoiding hospital admissions

9
Myths VAs Different . . .

• VAs Command Control
• Truth Yes, 17,000 staff physicians, but 25,000
  affiliated faculty 35,000 housestaff through
  affiliations with 107 academic health systems
• VA has an appropriated budget
• True, but VA 1.5 of 25 B (FY03) was revenue
  from billing, increased from 300 M, 3 years
  prior
• VAs patients are former military, thus overall
  healthier follow instructions
• VA patients define adverse selection
• Think of VA as Living Laboratory

10
Examples

• Medications Inpatient
• Bar Code Medication Administration
• Medications Outpatient (local initiatives)
• Drug Cost feedback
• Disease Management - Diabetes
• HgB A1c
• Outcomes
• Impact of Vaccinations
• Pneumovax
• Not having to pull charts or maintain a chart room

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INFORMATION TECHNOLOGY SAFETY
Bar Code Med Administration (BCMA)
12
What is the AssociatedCost Avoidance or Cost
Savings?
13
INFORMATION TECHNOLOGY EFFICIENCY
Using Technology to Manage Drug Costs
Drug Costs are listed in the order menu
14
INFORMATION TECHNOLOGY EFFICIENCY
Using Technology to Manage Drug Costs
Here Fluoxetine is listed as the preferred drug,
costs are also listed
15
INFORMATION TECHNOLOGY EFFICIENCY
Using Technology to Manage Drug Costs
Conversion from Citalopram to Fluoxetine
16
Diabetes Mellitus (DM)

• Prevalence of DM among VA patients is 20
• Substantially higher than in the general
  population
• More than 1 million patients per year
• Nearly all are male (2.4 women)
• Largest group is gt65 years old

17
Performance MeasurementSetting the U.S.
Benchmark for 18 Comparable Indicators
Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare
Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002)
Beta Blocker after MI 98 93 94 (NCQA 2002)
Breast Cancer Screening 84 75 75 (NCQA 2002)
Cervical Cancer Screening 90 62 81 (NCQA 2002)
Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001)
Cholesterol Screening (post MI) 94 78 79 (NCQA 2002)
LDL Cholesterol lt130 post MI 78 62 61 (NCQA 2002)
Colorectal Cancer Screening 67 NA 49 (BRFSS 2002)
Diabetes Hgb A1c checked past year 94 85 83 (NCQA 2002)
Diabetes Hgb A1c gt 9.5 (lower is better) 15 NA 34 (NCQA 2002)
Diabetes LDL Measured 95 88 85 (NCQA 2002)
Diabetes LDL lt 130 77 63 55 (NCQA 2002)
Diabetes Eye Exam 75 68 52 (NCQA 2002)
Diabetes Kidney Function 70 57 52 (NCQA 2002)
Hypertension BP lt 140/90 68 57 58 (NCQA 2002)
Influenza Immunization 76 P 68 (BRFSS 2002)
Pneumocooccal Immunization 90 P 63 (BRFSS 2002)
Mental Health F/U 30 D post D/C 77 61 74 (NCQA 2002)
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INFORMATION TECHNOLOGY QUALITY
CLINICAL REMINDERS
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INFORMATION TECHNOLOGY QUALITY
Effect of Clinical Reminders at 1 VAMC
20
INFORMATION TECHNOLOGY QUALITY
Effect of Clinical Reminders at 1 VAMC
21
Highest Quality of Care For Patients with
Diabetes in VA

• Diabetes processes of care and 2 of 3
  intermediate outcomes were better for patients in
  the VA system than for patients in commercial
  managed care.
• Annals of Internal Medicine, August 17, 2004

22
VA-TRIAD Adjusted Intermediate Outcomes
VA, CMC,
A1C level (proportion lt8.5) 83 65
A1C level (proportion lt9.5) 92 80
LDL level (proportion lt100) 52 36
LDL level (proportion lt130) 86 72
BP level (proportion lt130/80) 28 29
BP level (proportion lt140/90) 53 52
Plt0.001 Plt0.001 Plt0.001
Kerr et al Annals of Internal Medicine 2004 Kerr et al Annals of Internal Medicine 2004 Kerr et al Annals of Internal Medicine 2004
23
FY99-04 Changes in Total, Major and Minor
Age-Adjusted Amputation Rates Among Patients With
Diabetes
24
What is the AssociatedCost Avoidance or Cost
Savings?
25
Pneumococcal Vaccination Rates in VHA
--BRFSS 90th--
--BRFSS--

• Iowa Petersen, Med Care 199937502-9. gt65/ch dz
• HHS National Health Interview Survey, gt64

26
Pneumonia Acute InpatientImproving Efficiency
by Reducing Excess Health Care Utilization

• DRG89-90 Unadjusted for Pt. Population (up 20,
  FY99-01)

9,500 fewer bed days
8,000 fewer discharges
27
Vaccine Cuts Pneumonia Risk in High-Risk Patients

• 50 of elderly Americans / high-risk individuals
  have not received the pneumococcal vaccine.
• VA Medical Center study of 1,900 elderly patients
  with chronic lung disease 2/3 vaccinated against
  pneumonia.
• Pneumococcal vaccination
• 43 reduction in hospitalizations for pneumonia
  and influenza, and a 29 reduction in the risk of
  death.
• Pneumonia and Influenza vaccination
• 72 reduction in hospitalizations for these two
  diseases and an 82 reduction in deaths from all
  causes.
• Pneumococcal vaccination saved an average of 294
  per vaccine recipient over the 2-year period.
• Archives of Internal Medicine 19991592437-2442
  Dr. Kristin Nichol, VAMC / Minneapolis

28
Extrapolating from Dr. Nichols Study
Between 1996 and 1998, Increased Rates
of Pneumococcal Vaccination Averted 3914 Excess
Deaths Nationally in VHA Patients with Chronic
Lung Disease Today, over 6,000 lives have been
saved.
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What is the AssociatedCost Avoidance or Cost
Savings?
30
Priceless
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Paper versus Electronic Elimination of Processes

• Without an EHR
• Paper charts were pulled delivered to clinic
  locations for scheduled appointments
• Also involved re-filing
• Resulted in a 60 average chart availability rate
• One VA Medical Center
• Budget of 1 of the entire VHA
• Closed file room - cost avoidance estimated at
  600,000
• VERY Conservative estimate
• 1 per pull, delivery and re-file
• Some estimates in private sector as high as
  10/pull
• Eliminating this for VAs 50 million outpatient
  encounters ? estimated 50 million cost avoidance
  in staff resources

34
Home Telehealth
And what savings might we see from Home
Telehealth?
35
Home-Telehealth Technologies
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What is the AssociatedCost Avoidance or Cost
Savings?
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This presentation is available on the VHA
internet at

• www.va.gov/vha_oi
• Select Office of Information Document Library
  on the left hand bar
• Presentation is Titled
• AMIA 2005 - Presentation by Robert M. Kolodner
  M.D.
• http//www1.va.gov/vha_oi/docs/AMIA_2005_Panel.pps