HIT Return on Investment:

1

• HIT Return on Investment
• Evaluating Progress in a Sea of Change
• John Hsu, MD, MBA, MSCE
• AHRQ Conference
• 27 September 2007

2
HIT Background

• Great potential for transforming clinical care,
  especially for patients with chronic diseases
• Adoption of HIT across the U.S. is limited but
  growing
• Actual benefits of HIT unclear
• Initial benefits of HIT depend on how routinely
  and systematically clinicians use the HIT tools
  and resulting information
• Little information on HIT effects in the
  ambulatory setting with commercially-available
  systems
• Actual benefits and costs of HIT are difficult to
  quantify
• Comprehensive identification
• Methodological challenges

3
Preliminary Results - IMPACT Study

• Impact of Information Technology on Clinical
  Care
• An Evaluation of the Technology on Quality,
  Safety and Efficiency of Chronic Disease Care
• John Hsu, MD, MBA, MSCE (KP DOR)
• Ilana Graetz (KP DOR)
• Huihui Wang (KP DOR)
• Jie Huang, PhD (KP DOR)
• Mary Reed, DrPh (KP DOR)
• Bruce Fireman, MA (KP DOR)
• Joseph Selby, MD, MPH (KP DOR)
• Yvonne Zhou, PhD (KP)
• Jim Bellows, PhD (KP CMI)
• Naomi Bardach, MD (UCSF)
• Julian Wimbush (UCB)
• Tom Rundall, PhD (UCB)
• Robert Miller, PhD (UCSF)
• Richard Brand, PhD (UCSF)
• Funding AHRQ R01HS015280

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Overview

• Design
• Longitudinal study with quasi-experimental
  changes in exposure to HIT, and using a pre-post
  analytic design with concurrent controls
• Study Period 2004-2008
• Population IDS Members with any of five chronic
  diseases in January 2004 (Asthma, CAD, DM, HF,
  Htn)
• Data
• Automated databases
• Annual surveys

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Basic HIT Tools
  CIPS eChart eRx/eRefill eConsult eConsult
First Available 1995 March 2004 March 2004 March 2004 March 2004
Functions Functions Functions Functions Functions Functions
Data-Review Ö Ö Ö Ö  
Documentation   Ö      
Order-Entry     Ö Ö  
Communication   Ö
Paper-alternative No Yes Yes Yes Yes
Integrated Not integrated with other applications (i.e., need log onto each application separately) Not integrated with other applications (i.e., need log onto each application separately) Not integrated with other applications (i.e., need log onto each application separately) Not integrated with other applications (i.e., need log onto each application separately) Not integrated with other applications (i.e., need log onto each application separately)
Description     Viewing lab results Viewing medication list Writing free-text visit notes Using standard note templates Viewing medication list Viewing medication allergies Entering orders for new prescription or refills Requesting referrals or consultations Sending messages to other providers Requesting referrals or consultations Sending messages to other providers
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KP HealthConnect Ambulatory Suite
First Available Staggered implementation (2005-2008)
Functions Functions
Data-Review Ö
Documentation Ö
Order-Entry Ö
Communication  Ö
Paper-alternative No
Integrated Fully Integrated
Description     Viewing medication list, allergies, lab results Using standard note templates writing free-text visit notes Order new prescription or refills with decision support Ordering Disease-specific sets (drugs and labs) Sending messages to other providers requesting referrals or consultations Sending and receiving messages from patients Point-of-care access to decision-support tools including Online references and resources for current treatment guidelines Care Management Institute protocols, and standard tests/screens
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Potential Benefits of HIT

• Improved information availability (value of
  information)
• Clinical benefits
• Financial benefits e.g., greater efficiency,
  lower administrative costs, better coding

Benefits predicated on clinician use of HIT tools
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HIT Use
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HIT Implementation and Use
Among office visits in department of Medicine
or Family Practice
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CPOE Implementation and Use
New prescriptions are defined as new
prescriptions doctor wrote, can be refills for
existing drugs or completely new drugs
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HIT Use

• Implementation ? use
• Use of one type of HIT ? use of all HIT tools

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Information Quality
13
Data Availability Diagnoses Completed on Visit
Date
Among office visits in department of Medicine
or Family Practice
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Clinical Benefits
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Methodological Challenges for Assessing Clinical
Benefits

• Measures of use
• Temporal trends - concurrent control groups
• Patient- and physician-level differences
• Reliable pre-implementation clinical data -
  differentiating documentation vs. care
• Multi-level effects
• Adequate power

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Methods

• Study Period 04/2004-12/2006
• Study Population
• Active KPNC members who continuously enrolled
  during the study period
• 18 years and older as of 04/01/2004
• In diabetes registry as of 1st quarter of 2004
• Members in 5 medical centers where KPHC
  implemented before 07/2006 during the study
  period
• In teams which existed all the time during the
  study period
• With at least one LDL measurement in pre-HIT
  period and one in post-HIT period
• Predictor Measures Presence of HIT
  (HealthConnect)
• Model Mixed model with random effects at PCP and
  Patient level, adjusted for patient age, gender,
  race/ethnicity, neighborhood SES, time of
  measurement and Medical centers

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Definitions of Presence of HIT

• Definition 1 Medical center level KPHC rollout
  schedule
• HIT0 before KPHC was implemented at the first
  team in the medical center
• HIT1 within six months after KPHC was
  implemented at the first team in the medical
  center
• HIT2 six months after KPHC was implemented at
  the first team in the medical center
• Definition 2 Primary care team level actual use
• HIT 0 low use (lt80 at team level) of eChart
  or KPHC
• HIT 1 starting from the first month when
  eChart used gt80
• HIT 2 starting from the first month when KPHC
  used gt80

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Mean LDL in Each Month in KPNC
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Association between HIT and LDL
    Estimate 95 CI 95 CI
1. Implementation at Medical Center (roll-out schedule)     Before KPHC 1.00 ref. group   ref. group  
1. Implementation at Medical Center (roll-out schedule)     First 6 months of KPHC -0.50 -1.15 0.15
1. Implementation at Medical Center (roll-out schedule)     6 months of KPHC -0.64 -1.58 0.30
2. Actual use by Primary Care Team ( of total visits)     Low HIT use (lt80 of visits) 1.00 ref. group   ref. group  
2. Actual use by Primary Care Team ( of total visits)     EChart used in gt80 of visits -0.89 -1.55 -0.23
2. Actual use by Primary Care Team ( of total visits)     KPHC used in gt80 of visits -1.72 -2.68 -0.76
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Costs
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Investment

• Investment costs
• Equipment
• Personnel/productivity
• Training
• Maintenance costs
• IT support staff
• Future upgrades
• Continued training

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Other Relevant Features
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Dynamic Environment

• Changes in HIT
• Decision support
• Information use
• Changes in Care Delivery
• Clinical coordination
• Delivery system
• Changes in Medical Therapy
• Information on effectiveness
• Dissemination of new knowledge
• Changes in the Market
• Payment features, e.g., risk adjustment,
  reporting, performance incentives
• Payment mix

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Conclusions

• Benefits
• Some potential clinical benefits related to
  better information at the point-of-care
• Unclear benefits associated with improvements in
  clinical information at the system level
• Transaction benefits perhaps easiest to quantify
• Financial benefits depend market and
  reimbursement mix
• Costs
• Investment costs beyond equipment costs can be
  difficult to quantify
• Maintenance costs also important
• Dynamic/changing systems and markets....

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Summary Need for Better Empirical Studies
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HIT as Basic Infrastructure