Health IT

1
Health IT

• What went wrong, how do we avoid repeating
  mistakes ?
• Jack Glode, MD, FACC

2
Major Barriers to Adoption

• Cost
• Lack of interoperability
• Privacy/Security concerns
• Product shortfalls
• Exaggerated benefits not realized
• Proprietary interests of vendors and the
  healthcare delivery system

3
Cost

• Frolich et al.,Retrospective Lessons Learned
  from the Santa Barbara Project and Their
  Implications for Health Information Exchange,
  Health Affairs August 2007
• The Santa Barbara County Care Data Exchange What
  Happened, Miller, Health Affairs, August 2007.
  Lack of a compelling value proposition for
  potential investors was the main cause of the
  Santa Barbara Projects demise.

4
Cost

• Medical Groups Adoption Of Electronic Health
  Records And Information Systems, Gans, Health
  Affairs, 2005. ..would translate into about a
  10 reduction in take-home pay each year for
  most primary care practices ( assuming all IT
  costs paid by the practice)

5
Cost

• It Aint Necessarily So The Electronic Health
  Record And The Unlikely Prospect Of Reducing Heal
  Care Costs, Sidorov, Health Affairs,2006. A
  considerable body of evidence suggests that
  widespread adoption of EHR increases health care
  costs the EHR has yet to be quantified or
  consistently used to reduce malpractice premiums
  or health care costs

6
Cost

• QI gains may justify incurring the short-term
  financial losses- and therefore justify a CHCs
  investment in an EHR- but only if the CHC rapidly
  and extensively used the EHR for QI., Robert
  Miller, PhD,UCSF

7
Cost

• Whether RHIOs represent small businesses that
  need viable business models, which requires the
  ability to generate profits as well as value for
  participants, or public goods that require public
  financing is an important unresolved issue. The
  State of Regional Health Information
  Organizations Current Activities and Financing,
  Milstein, Health Affairs, 2008

8
Interoperability

• .opposition to portable health information is,
  by definition, support for proprietary health
  information. Think what it would be like to be in
  an emergency room where a doctor cant make
  lifesaving decisions because your health
  information is at a competing hospital.we have
  one chance to get it right, and that means making
  portable health information our priority-David
  Brailer

9
Interoperability

• EHRs and community-based health information
  networks have been slow to develop because of a
  lack of interoperability standards to support
  electronic data exchange. Steven Redhead, CRS
  Report for Congress 2005

10
Interoperability

• The hospitals and some offices are preparing to
  install potentially different EHR systems, and
  all want us to be expert users in their systems,
  Steven Benton, M.D., FACC, Cardiology, 2007
• Wyoming has 160 vendors selling these products,
  with no intention/means of becoming interoperable
  with competitors

11
Interoperability

• A key problem today in the realization of EHRs
  for the patients continuity of care( RUPRI
  report), is the inability to share patient
  records across disparate enterprises., Dr.
  William Jeffrey, Committee on Science, U.S. House
  of Representatives, 2006

12
Interoperability

• Health Information Exchange Why Centralized Data
  Banks Wont Work, Rex Gantenbein, Ph.D.
• Considerable resistance to centralized
  database in Wyoming, (John Snow, Final Report to
  the WHCC)
• Provides a target for hackers
• Physicians in England are rebelling against a
  national data warehouse, because of privacy and
  security concerns
• Federated model addresses these concerns (in
  depth discussion at Dec. 1 Whio meeting)

13
Interoperability

• UHIN has issued an RFP for an interoperability
  solution for Utah
• Community, patient centric, with emphasis on
  privacy/security and access to patient
  information at the point of care,
• Must be able to both push information to known
  entities and to query the system to collect
  information about a single patient from multiple
  data sources (with appropriate authorization)

14
Interoperability

• Competition among hospitals for physicians is a
  key factor driving adoption of proprietary
  systems. In contrast, provider and health plan
  competition and adversarial relationships between
  providers and plans are viewed as major barriers
  to communitywide clinical data sharing.
  Hospital-Physician Portals the Role of
  Competition in Driving Clinical Data Exchange,
  Grossman, Health Affairs,2006

15
Perceived Benefits of Medical IT

• Eric Poon, MD MPH, Brigham and Womens Hospital,
  Boston, MA, Lecture at Patient Safety Conference,
  WHCC, Cheyenne, Wy., April 2006
• Myth 1-If providers could just find the
  capital to buy the hardware and software, wed
  see clinical IT everywhere.

16
Benefits

• Debunking Myth 1
• Most applications dont work terribly well
  off-the-shelf (yet)
• Need to spend time to customize
• Training and leadership can shorten
  recovery time

17
Benefits

• Poon Myth 2- Lets install the application with
  the best features and everyone will just love the
  EMR
• build it and they will come
• The docs are smart. Theyll figure out how
  to use this new toy

18
Benefits

• Debunking Myth 2
• Changing peoples workflow is very hard
• Leadership, workflow redesign
• No-one can drink from a fire-hydrant
• Small can be beautiful

19
Benefits

• Myth 3 - Information technology will largely
  solve the problem of medical errors
• Debunking 3
• Its all about better team work,
  communication and rational standardization
• IT can facilitate these processes
• Installing IT gives you an opportunity to
  address previous broken processes
• Every time you put a new process in place, you
  create opportunities for errors

20
Benefits

• Poon- Let the clinical process drive IT, not vice
  versa
• Never skimp on training and support (
  role for Whio?)
• Leadership and vision
• Relentless focus on workflow, (what
  will work best at the point of care ? What will
  be counterproductive)

21
Benefits

• RUPRI WHCC Report- Abandon top down approach and
  do assessment at local level to determine IT
  needs, place in clinical context
• Docs need help with vendor assessment( role
  for WHio)

22
Benefits

• Coupled with a nearly 50 failure rate for EHRs,
  it is no wonder that many physician practices
  find the decision so daunting to move forward
  technologically, Evan Steel,CEO of SRS Software,
  Healthcare IT News. March 2006
• Siderov- Not all reports on CPOE are positive.
  Its introduction in one pediatric ICU led to an
  increase in mortality rates that was blamed on
  delays and increased documentation time,
  compounded by policies that diminished access to
  life-saving therapies
• AS implemented, EHRs were not associated with
  better quality(17 quality indicators) ambulatory
  care, Linder, et al., Arch Intern Med, 2007
  (Brigham and Womens and Harvard School ,
  Stanford University)

23
Privacy and Security

• Federal legislation for privacy and security,
  Bills in House and Senate were at odds, (see
  comments by Brailer), Dr Peel of Patient Privacy
  Rights Foundation says the bill doesnt have much
  of a chance of passage due to heavy lobbying from
  companies interested in data mining
• GAO says HHS lacks strategy for ensuring HIT
  privacy 2006

24
Summary

• Wyoming needs a RHIO to address these issues,
  providing enlightened leadership, research,
  vendor evaluation, assisting in implementing
  measures to improve the healthcare delivery
  system as recommended in the RUPRI/WHCC report
• We cannot rely on grants to sustain these
  efforts, public-private partnerships must be
  developed and a solid business case must be
  established
• Interoperability with privacy/security assured
  must be a top priority

25
Summary

• Can we connect 160 different applications (vendor
  products)? System presented on Dec. 1, may be
  others?
• IT must be placed in proper clinical context with
  careful design to avoid failures of the pastwe
  should resist exaggerated claims for the benefit
  of IT in and of itself
• Use common sense we need patient information
  from all sources at the point of care as our
  first priority, i.e. lab and radiology reports,
  reliable medication lists, history of illnesses
• Once interoperability is established, unlimited
  IT applications are possible research, patient
  registries, disease management, programs to
  improve population health, improving the
  continuum of care, education
• Special need for Telemedicine to improve the
  delivery system in rural Wyoming? (RUPRI/WHCC)