1 health information technology citizen’s health care working group presented by scott d....
TRANSCRIPT
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Health Information Health Information TechnologyTechnology
Citizen’s Health Care Working GroupCitizen’s Health Care Working Group
Presented byPresented by
Scott D. Williams, M.D., M.P.H.Scott D. Williams, M.D., M.P.H.
Vice-President, HealthInsightVice-President, HealthInsight
July 22, 2005July 22, 2005
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OverviewOverview• HealthInsightHealthInsight
Medicare Quality Improvement Organization (QIO) with Medicare Quality Improvement Organization (QIO) with CMS contract for Utah and NevadaCMS contract for Utah and Nevada
DOQ-IT Project PilotDOQ-IT Project Pilot• Promoting the use of Electronic Medical Records in small and Promoting the use of Electronic Medical Records in small and
medium primary care physician officesmedium primary care physician offices
• Utah Health Information Network (UHIN)Utah Health Information Network (UHIN) 12 years of successful administrative health data exchange 12 years of successful administrative health data exchange
• Claims, remittance, eligibilityClaims, remittance, eligibility• Credentialing, coordination of benefits, EFT Credentialing, coordination of benefits, EFT
Regional Health Information Organization development Regional Health Information Organization development grantee (AHRQ)grantee (AHRQ)
• Labs, pharmacy, clinical notes and reportsLabs, pharmacy, clinical notes and reports
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Issues in Health ITIssues in Health IT• TechnologyTechnology
• ArchitectureArchitecture• Hardware/ SoftwareHardware/ Software• ConnectionsConnections• SupportSupport
• GovernanceGovernance• Community Community
interestsinterests• Privacy, securityPrivacy, security• Resource allocationResource allocation
• ValueValue• Who benefits & Who benefits &
who pays?who pays?• EfficiencyEfficiency• OutcomesOutcomes
• StandardsStandards• Self-regulatedSelf-regulated• Externally- Externally-
regulatedregulated• Market drivenMarket driven
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Health IT: ApplicationsHealth IT: Applications
• Electronic Medical Record (EMR)Electronic Medical Record (EMR)Paperless officePaperless officePersonal Health RecordPersonal Health Record
• Health Information Exchange (HIE)Health Information Exchange (HIE)Regional Health Information Org. (RHIO)Regional Health Information Org. (RHIO)Allows interoperability between stakeholdersAllows interoperability between stakeholders
• Clinical Decision Support Systems (CDSS)Clinical Decision Support Systems (CDSS)Case and cohort managementCase and cohort managementComputerized Physician Order Entry (CPOE)Computerized Physician Order Entry (CPOE)Prompts, recalls, trends, protocols, drug Prompts, recalls, trends, protocols, drug
interactions, generics, performance measures interactions, generics, performance measures
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Value: Administrative Health DataValue: Administrative Health Data• UHIN (17 million claims/year)UHIN (17 million claims/year)
Efficiency of Claims Processing by 1 adjudicatorEfficiency of Claims Processing by 1 adjudicator• Paper Paper 100-150/ day100-150/ day• Scanned Scanned 300/ day300/ day• EDI EDI 700-800/ day700-800/ day• AutoprocessingAutoprocessing 60% of claims require no 60% of claims require no
human involvement human involvementPayer value- just for intake of claimPayer value- just for intake of claim
• Paper = $6-10/ claimPaper = $6-10/ claim• EDI < $1/ claimEDI < $1/ claim
Provider valueProvider value• Faster paymentsFaster payments• Fewer rejected claimsFewer rejected claims• Less staff timeLess staff time
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Lessons Learned: UHIN Lessons Learned: UHIN
• Champion- credible, neutral, trustedChampion- credible, neutral, trusted• Value accrues to all participantsValue accrues to all participants
Drives prioritiesDrives prioritiesDrives business modelDrives business model
• Community ownership & governanceCommunity ownership & governanceConsensus decision makingConsensus decision making
• Standards drivenStandards driven• Use of data subject to governance Use of data subject to governance
processprocess
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Value: EMRsValue: EMRs
HIMSS, September 2004
EMR Adoption
Physician Offices 17%
Hospital ER 31%
Hospital Outpatient 29%
CDC March 2005
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Value: EMR Adoption Barriers Value: EMR Adoption Barriers among Physiciansamong Physicians
• Initial Capital Cost Initial Capital Cost (345/423, ms = 1.85)(345/423, ms = 1.85)
• Time Cost Time Cost (323/423, ms = 2.74)(323/423, ms = 2.74)
• Confidentiality and Confidentiality and Security Concerns Security Concerns (181/423, ms = 2.93)(181/423, ms = 2.93)
• Maintenance cost Maintenance cost (300/423, ms = 3.00)(300/423, ms = 3.00)
• Interfere with doctor-Interfere with doctor-patient communicationpatient communication
• Concerns about Concerns about learning new learning new technologytechnology
• Lack of technical Lack of technical supportsupport
• Lack of control over Lack of control over decisiondecision
• Lack of perceived Lack of perceived benefitsbenefits
ms = mean score
Massachusetts Medical Society Survey Spring 2003
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Value: EMR Business Case for the Value: EMR Business Case for the PhysicianPhysician
• Process efficiency (requires workflow redesign)Process efficiency (requires workflow redesign) TranscriptionTranscription FormsForms Telephone callsTelephone calls Information collection from patientsInformation collection from patients
• Lower overheadLower overhead Fewer FTEsFewer FTEs Less space needed for chartsLess space needed for charts
• Increased reimbursementIncreased reimbursement Better coding & recoveryBetter coding & recovery More patients seen (if workflow changes)More patients seen (if workflow changes) Pay for PerformancePay for Performance
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Value: EMR Business Case for the Value: EMR Business Case for the PhysicianPhysician
Mean BenefitMean Benefit Low EndLow End High EndHigh End
Savings (paperless, Savings (paperless, capitated = 17%, capitated = 17%,
Fee for service = 83%)Fee for service = 83%)
$50,300$50,300 $21,800$21,800 $85,600$85,600
Costs, Year 1 (hardware, Costs, Year 1 (hardware, software, inefficiency, software, inefficiency, licenses, support, licenses, support, updates)updates)
$22,100$22,100 $13,700$13,700 $36,000$36,000
Costs, Year 2 +Costs, Year 2 + $5,300$5,300 $2,600$2,600 $9,500$9,500
Total ROI, Year 1Total ROI, Year 1 $28,200$28,200 $8,000$8,000 $49,600$49,600
Total ROI, Year 2+Total ROI, Year 2+ $45,000$45,000 $19,000$19,000 $76,100$76,100
Wang, S.J. et al. 2003
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Value: EMR Business Case for the Value: EMR Business Case for the PhysicianPhysician
Wenner Georgia HIMSS Dec 2002
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Value: EMR Business Case for the Value: EMR Business Case for the PhysicianPhysician
Wenner Georgia HIMSS Dec 2002
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Value: HIEValue: HIE
• Automation of clinical processesAutomation of clinical processes
• More timely, complete, accurate More timely, complete, accurate patient information at point of patient information at point of serviceservice
• Efficiency of connectivityEfficiency of connectivity
• Facilitate clinical decision support Facilitate clinical decision support systems across communitiessystems across communities
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Value: HIEValue: HIE• Missing Patient DataMissing Patient Data
13.6% of primary care physician visits13.6% of primary care physician visits52% of missing data resides outside of system52% of missing data resides outside of system44% of data somewhat likely to adversely affect 44% of data somewhat likely to adversely affect
patientspatients60% of data likely to delay care or result in 60% of data likely to delay care or result in
additional servicesadditional servicesMore likely among recent immigrants, new patients, More likely among recent immigrants, new patients,
those with complex medical problemsthose with complex medical problemsLess likely where physician has full EMR and also Less likely where physician has full EMR and also
in rural areasin rural areas
Smith et al. JAMA. February 2005
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Hospitals
Primary care physician
Specialty physician
Ambulatory center (e.g.
imaging centers)
Payors
Pharmacy
Laboratory
Public health
Current system fragments patient information and creates redundant, inefficient efforts
Pharmacy
Laboratory
Hospitals
Primary care physician
Specialty physician
Ambulatory center (e.g.
imaging centers)
Payors
Public health
HealthInformationExchange
Future system will consolidate information and provide a foundation for unifying efforts
Source: Indiana Health Information Exchange
RHIOs: “Wiring” Healthcare RHIOs: “Wiring” Healthcare EfficientlyEfficiently
RHIOs: “Wiring” Healthcare RHIOs: “Wiring” Healthcare EfficientlyEfficiently
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Value: HIEValue: HIE• Based on published data and expert opinionBased on published data and expert opinion• Interoperability Interoperability
Level 2 = FaxLevel 2 = Fax Level 3 = Machine-organizable dataLevel 3 = Machine-organizable data Level 4 = Machine-interpretable dataLevel 4 = Machine-interpretable data
• Net Value after full implementationNet Value after full implementation Level 2 = $21.6 billion /yearLevel 2 = $21.6 billion /year Level 3 = $23.9 billion/ yearLevel 3 = $23.9 billion/ year Level 4 = $77.8 billion/ yearLevel 4 = $77.8 billion/ year
• Costs: Benefit Calculation for Costs: Benefit Calculation for Level 4Level 4 Years 1-10 = $276 billion: $613 billion = $338 billionYears 1-10 = $276 billion: $613 billion = $338 billion Year 11 + = $16.5 billion: $94.3 billion = $77.8 billionYear 11 + = $16.5 billion: $94.3 billion = $77.8 billion
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIEValue: Level 4 HIE• Contributions to the $94.3 billion benefit: Service categoriesContributions to the $94.3 billion benefit: Service categories
• Contributions to the $16.5 billion costContributions to the $16.5 billion cost
Laboratory testingLaboratory testing $31.8 billion$31.8 billion
ImagingImaging $26.2 billion$26.2 billion
Provider-payer transactionsProvider-payer transactions $20.1 billion$20.1 billion
Chart transfers between providersChart transfers between providers $13.2 billion$13.2 billion
PharmacyPharmacy $2.71 billion$2.71 billion
Public health reportingPublic health reporting $195 million$195 million
Clinical office system costClinical office system cost $9.08 billion$9.08 billion
Hospital system costHospital system cost $1.58 billion$1.58 billion
Provider interface costProvider interface cost $5.40 billion$5.40 billion
Stakeholder interface costStakeholder interface cost $467 million$467 million
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIEValue: Level 4 HIE
ProvidersProviders $33.7 billion$33.7 billion
PayersPayers $27.6 billion$27.6 billion
LaboratoriesLaboratories $13.1 billion$13.1 billion
Radiology centersRadiology centers $8.2 billion$8.2 billion
PharmaciesPharmacies $1.3 billion$1.3 billion
Public health departmentsPublic health departments $94 million$94 million
•Where does $77.8 billion net value accrue (HIE Only)?Where does $77.8 billion net value accrue (HIE Only)?
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIEValue: Level 4 HIE
• 50-200 Bed Hospital50-200 Bed Hospital$2.7 million in IT investment$2.7 million in IT investment$250,000/year in maintenance$250,000/year in maintenance$1.3 million/year in transaction savings$1.3 million/year in transaction savings
• $570,000 from other providers$570,000 from other providers• $200,000 from other laboratories$200,000 from other laboratories• $170,000 from radiology centers$170,000 from radiology centers• $250,000 from payers$250,000 from payers• $70,000 from pharmacies$70,000 from pharmacies
Walker et al. Health Affairs. January 2005
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HIE: UHIN ApproachHIE: UHIN Approach
• Identify value-based priority use Identify value-based priority use cases with interested stakeholderscases with interested stakeholders
• Obtain broader stakeholder supportObtain broader stakeholder support• Develop and adopt technical modelDevelop and adopt technical model• Develop and adopt financing modelDevelop and adopt financing model• Convene standards development Convene standards development
processprocess• Adopt standardsAdopt standards• Pilot, refine, implementPilot, refine, implement
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“...risk-adjusted cost varied almost 3-fold...”
Duke Clinical Research Institute 2002
70%
30%
Project Hope, Wennberg et.al., 2003/HealthAlliant
“...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
“...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
“...The cost of poor quality in health care is as much as 60% of costs...”
Brent James, M.D., IHC.
“...30% of direct health care outlays are the result of poor-quality care...”
MBGH, Juran, et al 2002
Practice Variation
Value: CDSSValue: CDSS
Annual U.S. health care expenditures: $1.7 trillion x 30% = ~ $500 billion
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Value: CDSSValue: CDSSCPOECPOE
• 25% improvement in ordering of 25% improvement in ordering of corollary medications by faculty corollary medications by faculty and residents (p<0.0001) Overhage, and residents (p<0.0001) Overhage, 19971997
• 55% decrease in non-intercepted 55% decrease in non-intercepted serious medication errors (p=0.01) serious medication errors (p=0.01) Bates, 1999Bates, 1999
• 81% decrease in medication errors 81% decrease in medication errors
(p<0.0001) Bates, 1999 (p<0.0001) Bates, 1999
• Improvement in 5 prescribing Improvement in 5 prescribing practices (p<0.001) Teich, 2000practices (p<0.001) Teich, 2000
CDSSCDSS
• 6 of 14 studies showed 6 of 14 studies showed improvement in patient improvement in patient outcomes. Hunt 1998outcomes. Hunt 1998
• 43 of 65 studies showed 43 of 65 studies showed improvement in physician improvement in physician performance. Hunt 1998performance. Hunt 1998
• 17% improvement in antibiotic 17% improvement in antibiotic regimen suggested by computer regimen suggested by computer consultant versus physicians consultant versus physicians (p<0.001) Evans 1994(p<0.001) Evans 1994
• 70% decrease in adverse drug 70% decrease in adverse drug events caused by anti-infectives events caused by anti-infectives (p=0.02) Evans 1998(p=0.02) Evans 1998
Source: Center for Information Technology Leadership, 2003
23Source: SBCCDE, CITL, Gordian Project analysis
Redundancy
Treatment
Errors
Diagnostic
EMR HIE CDSS
Patient Data
Medical Knowledge
50% of Cost20% of Return
100%
Value: CDSSValue: CDSS
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Value: Outpatient CPOEValue: Outpatient CPOE
• Savings from nationwide adoptionSavings from nationwide adoptionAdverse Drug Reactions = $2 billionAdverse Drug Reactions = $2 billion
• Eliminate 2 million adverse drug reactionsEliminate 2 million adverse drug reactions• Eliminate 190,000 hospitalizationsEliminate 190,000 hospitalizations
Medication management = $27 billionMedication management = $27 billionRadiology management = $10.4 billionRadiology management = $10.4 billionLaboratory management = $4.7 billionLaboratory management = $4.7 billion
Total = $44 billionTotal = $44 billionSource: Center for Information Technology Leadership, 2003
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Value: Who benefits? Value: Who benefits? Who Pays?Who Pays?
% of Savings Captured by
11%89% Physicians
Source: Center for Information Technology Leadership, 2003
Ambulatory Computer-based Physician Order Entry
Private Payers
Medicare
Medicaid
Self-insured
Self-pay
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Health IT: Federal Government RolesHealth IT: Federal Government Roles
• Facilitate the implementation of a national Facilitate the implementation of a national strategystrategy
• Support innovation experimentsSupport innovation experiments• Confirm business value and align incentivesConfirm business value and align incentives• Coordinate the implementation strategies of Coordinate the implementation strategies of
federal health care agenciesfederal health care agencies• Assure the rapid development of data and Assure the rapid development of data and
technical standards with broad inputtechnical standards with broad input• Assure that privacy and security regulations Assure that privacy and security regulations
don’t encumber interstate health data exchangedon’t encumber interstate health data exchange• Incentivize health IT savings to be redirected into Incentivize health IT savings to be redirected into
effective health care interventionseffective health care interventions