Health Information Technology inHealth Information Technology inCommunity Health Centers Community Health Centers ––

A Health Improvement A Health Improvement OpportunityOpportunity

David Campbell, CEOCommunity Health Network

of West Virginia

NCSL June 20, 2007

Community Health Network Community Health Network of West Virginiaof West Virginia

The Network is a taxThe Network is a tax--exempt, nonexempt, non--profit health profit health centercenter-- controlled West Virginia corporation.controlled West Virginia corporation.The nineteen Network member health center The nineteen Network member health center organizations collectively provide services to organizations collectively provide services to over 120,000 patients in 32 of West Virginia’s 55 over 120,000 patients in 32 of West Virginia’s 55 counties each year, with 78 delivery sites and counties each year, with 78 delivery sites and nearly 400,000 patient encounters annually.nearly 400,000 patient encounters annually.Our member health centers provided over $40 Our member health centers provided over $40 million in health care services last year, with million in health care services last year, with 70% of this care to Medicare, Medicaid and 70% of this care to Medicare, Medicaid and uninsured patients.uninsured patients.

West Virginia is a rural state:West Virginia is a rural state:SixtySixty--four percent of the state’s population lives four percent of the state’s population lives in a rural area. in a rural area. FortyForty--five of West Virginia’s fiftyfive of West Virginia’s fifty--five counties are five counties are designated as rural. designated as rural. TwentyTwenty--three of the fiftythree of the fifty--five counties have fewer five counties have fewer than 45 residents per square mile.than 45 residents per square mile.Fifty counties have some portion of the county Fifty counties have some portion of the county designated as a medically underserved area and designated as a medically underserved area and thirtythirty--seven counties have some portion seven counties have some portion designated as a health professional shortage designated as a health professional shortage area.area.

Health care delivery in West VirginiaHealth care delivery in West Virginia

54 acute care community hospitals, 18 critical access hospitals,54 acute care community hospitals, 18 critical access hospitals, with with a total of 70 hospitals; a total of 70 hospitals; Seven stateSeven state--operated facilities, 2 behavioral health facilities, four operated facilities, 2 behavioral health facilities, four longlong--term care, one community hospital (all implementing a version term care, one community hospital (all implementing a version of the VA’s Vista EHR);of the VA’s Vista EHR);14 behavioral health centers, and 65 certified intermediate care14 behavioral health centers, and 65 certified intermediate carefacilities;facilities;34 nonprofit primary care centers, with 139 primary care service34 nonprofit primary care centers, with 139 primary care servicesites (including 41 schoolsites (including 41 school--based health centers), providing services based health centers), providing services in or to 47 counties;in or to 47 counties;54 local health departments, 73 home health agencies and 20 54 local health departments, 73 home health agencies and 20 hospice organizations; hospice organizations; 3,743 MDs and 507 3,743 MDs and 507 DOsDOs active and practicing in West Virginia active and practicing in West Virginia according to the respective licensing boards. Approximately oneaccording to the respective licensing boards. Approximately one--third of West Virginia’s physicians are selfthird of West Virginia’s physicians are self--employed in a solo employed in a solo practice. More than onepractice. More than one--third of West Virginia’s physicians provide third of West Virginia’s physicians provide primary care.primary care.

Health Care Utilization in West VirginiaHealth Care Utilization in West Virginia

293,093 Hospital discharges in 2006;293,093 Hospital discharges in 2006;3.3 million nursing home patient days;3.3 million nursing home patient days;600,000 hospital outpatient encounters, 1.0 ER visits 600,000 hospital outpatient encounters, 1.0 ER visits (twice the national average);(twice the national average);6 million ambulatory care encounters, 2 million of which 6 million ambulatory care encounters, 2 million of which were primary care visits (half in practices of less than were primary care visits (half in practices of less than five providers);five providers);27 million filled prescriptions (15 per capita) at a cost of 27 million filled prescriptions (15 per capita) at a cost of $1.5 billion;$1.5 billion;Total hospital cost $4 billion; $2.6 for professional Total hospital cost $4 billion; $2.6 for professional services; andservices; and6.5 million laboratory tests6.5 million laboratory tests

The health of West VirginiaThe health of West Virginiacreated a need for a populationcreated a need for a population--focused focused

health improvement toolhealth improvement toolOf West Virginia adults: Of West Virginia adults:

64% are obese or overweight;64% are obese or overweight;32.4% have high blood pressure (with another 28% at32.4% have high blood pressure (with another 28% at--risk with prerisk with pre--hypertension);hypertension);37.5% have high cholesterol;37.5% have high cholesterol;28.2% are current smokers;28.2% are current smokers;9.8% have been diagnosed with diabetes (and another 9.8% have been diagnosed with diabetes (and another 3% are undiagnosed diabetics);3% are undiagnosed diabetics);40% are pre40% are pre--diabetic; anddiabetic; and85% have one or more risk factors for chronic disease.85% have one or more risk factors for chronic disease.

(Source: West Virginia Department of Health and Human (Source: West Virginia Department of Health and Human Resources)Resources)

The Network health improvement programThe Network health improvement program

The Network and its members have identified a The Network and its members have identified a number of significant health improvement number of significant health improvement opportunities and have targeted:opportunities and have targeted:diabetes, diabetes, cardiovascular risk reduction, cardiovascular risk reduction, depression, depression, weight management and physical activity, weight management and physical activity, asthma; andasthma; andcessation of tobacco usecessation of tobacco use

as focus areas of its health improvement programas focus areas of its health improvement program..

Why focus on health improvement? The Why focus on health improvement? The impact of complications of diabetes:impact of complications of diabetes:

People with diabetes have:People with diabetes have:4 times risk for blindness4 times risk for blindness22--4 times risk for heart attack4 times risk for heart attack19 times risk for kidney disease19 times risk for kidney disease28 times risk for limb amputation28 times risk for limb amputation

The average lifetime cost of each new case of diabetes The average lifetime cost of each new case of diabetes is $250,000. is $250,000.

The average lifetime care for each new case of heart The average lifetime care for each new case of heart disease is nearly $500,000. disease is nearly $500,000.

A person diagnosed with diabetes at age 40 faces 10 A person diagnosed with diabetes at age 40 faces 10 years of life lost prematurely.years of life lost prematurely.

MedLynksMedLynks is a unique adaptation is a unique adaptation of a public domain solutionof a public domain solution

MedLynksMedLynks is an adaptation of the RPMS is an adaptation of the RPMS software used by Indian Health Service (IHS). software used by Indian Health Service (IHS). RPMS is public domain software that is an RPMS is public domain software that is an awardaward--winning health improvement tool used by winning health improvement tool used by a HRSAa HRSA--funded agency, IHS. funded agency, IHS. It has UDS and FQHC compatible functionality It has UDS and FQHC compatible functionality and a number of clinical data collection and and a number of clinical data collection and reporting tools. reporting tools. The Network is the first in the country to adapt a The Network is the first in the country to adapt a public domain solution for use in the community public domain solution for use in the community health setting.health setting.

Why develop MedLynks instead of Why develop MedLynks instead of purchasing a commercial product?purchasing a commercial product?

Based upon proven and stable RPMS used by Based upon proven and stable RPMS used by IHS for populationIHS for population--based health improvement based health improvement and also utilizes VA’s Vistaand also utilizes VA’s Vista--base for clinical base for clinical flexibility. RPMS used in 69 IHS facilities and flexibility. RPMS used in 69 IHS facilities and selected by NASA for use in occupational health. selected by NASA for use in occupational health. RPMS is public domain software.RPMS is public domain software.State of WV implementing Vista in seven stateState of WV implementing Vista in seven state--owned facilities. Access to national templates owned facilities. Access to national templates and health improvement processes. and health improvement processes.

Why develop MedLynks instead of Why develop MedLynks instead of purchasing a commercial product?purchasing a commercial product?

Most commercial systems provide for Most commercial systems provide for electronic documentation of existing health electronic documentation of existing health care delivery process, not a transformation care delivery process, not a transformation vehicle for health improvement.vehicle for health improvement.Our members want to deliver superior Our members want to deliver superior care.care.Funded by HRSA ICT grant for adaptation.Funded by HRSA ICT grant for adaptation.

EHR adoption by CHCsEHR adoption by CHCs

In 2004, 914 federally qualified health centers In 2004, 914 federally qualified health centers (FQHCs) provided medical and dental primary (FQHCs) provided medical and dental primary care services to 13.1 million patients. care services to 13.1 million patients. Almost 10,000 fullAlmost 10,000 full--timetime--equivalent (FTE) equivalent (FTE) physicians, nurse practitioners, physician physicians, nurse practitioners, physician assistants, and certified nurse midwives assistants, and certified nurse midwives provided care. provided care. Study found that EHRStudy found that EHR--related benefits for most related benefits for most CHCs did not pay for ongoing EHR costs, yet CHCs did not pay for ongoing EHR costs, yet quality improvement (QI) was substantial.quality improvement (QI) was substantial.

EHR adoption by CHCsEHR adoption by CHCsMaking some rough assumptions, CHCs will need $550 million–$1.1 billion, or $55–$110 million per year spread over ten years, to pay for EHRs, including technical and organizational assistance.

Assumptions include a ten-year EHR implementation period in the CHC sector, $35,000–$50,000 per FTE provider in initial costs, and an average $5,000–$15,000 per provider net annual cost in the first four years post-implementation.

Source: Source: The Value Of Electronic Health Records In Community Health Centers: Policy Implications Health Affairs, 26, no. 1 (2007): 206-214

EHR adoption by CHCsEHR adoption by CHCsInitial EHR costs per FTE billing provider averaged almost $54,000. 30% hardware ($17,022)28% software ($15,697)22% installation/training ($11,999)12% lost productivity ($6,763) 8% other/connectivity (4,164)Ongoing costs per FTE provider per year averaged $20,610.Initial costs averaged $16.20 per medical encounter and ongoing costs averaged $6.21 per medical encounterCHCs had higher EHR costs and lower financial benefits, and they made much greater QI efforts.

Source: Source: The Value Of Electronic Health Records In Community Health Centers: Policy Implications Health Affairs, 26, no. 1 (2007): 206-214

Advantage of Network Advantage of Network deployment of deployment of MedLynksMedLynks

Centralized hosting, reducing hardware cost;Centralized hosting, reducing hardware cost;Centralized support and staffing, reducing ongoing Centralized support and staffing, reducing ongoing support costs and clinical application support; support costs and clinical application support; Use of public domain solution reduces software licensing Use of public domain solution reduces software licensing fees (some for certain applications and national codes, fees (some for certain applications and national codes, i.e., CPT, ICD);i.e., CPT, ICD);Access to national templates and tools of IHS and VA Access to national templates and tools of IHS and VA reduces some setreduces some set--up costs;up costs;Average cost is $4,000 per FTE (compared to $26,000 in Average cost is $4,000 per FTE (compared to $26,000 in Health Affairs study) for setHealth Affairs study) for set--up and training, less under up and training, less under ASP standard configuration deployment; ASP standard configuration deployment; OnOn--going cost is $200 to $400 per FTE per month going cost is $200 to $400 per FTE per month (compared to $1,400 in Health Affairs study).(compared to $1,400 in Health Affairs study).

MedLynks development is coordinated with MedLynks development is coordinated with participation in participation in

West Virginia Medicaid RedesignWest Virginia Medicaid RedesignSystem needs to:System needs to:

support enhanced access to preventive and support enhanced access to preventive and disease management services, defined personal disease management services, defined personal health management goals and responsibilities health management goals and responsibilities and rewards for healthy behavior;and rewards for healthy behavior;meet needs of “Advanced Medical Home”;meet needs of “Advanced Medical Home”;provide integration with telehealth applications; provide integration with telehealth applications; andandfacilitate advanced planned care with strong facilitate advanced planned care with strong selfself--management components.management components.

Public policy considerationsPublic policy considerationsfor HIT in community health settingsfor HIT in community health settings

Health care providers get only about 11 percent of the Health care providers get only about 11 percent of the savings from electronic health records; the real benefit savings from electronic health records; the real benefit goes mainly to private and public insurers because they goes mainly to private and public insurers because they are paying for fewer unnecessary tests and automated are paying for fewer unnecessary tests and automated recordrecord--handling is a big cost saving for the payers; handling is a big cost saving for the payers; Significant savings are possible in use of EHR, but initial Significant savings are possible in use of EHR, but initial and ongoing cost is a barrier to adoption in light of how and ongoing cost is a barrier to adoption in light of how the benefit from adoption and use flows (above);the benefit from adoption and use flows (above);An estimated oneAn estimated one--fourth of primaryfourth of primary--care doctors use care doctors use electronic health records, but only 5 percent of them are electronic health records, but only 5 percent of them are in offices with five doctors or fewer in offices with five doctors or fewer —— where about half where about half of all doctors practice. of all doctors practice.

Public policy considerationsPublic policy considerationsfor HIT in community health settingsfor HIT in community health settings

Research demonstrates that preventive Research demonstrates that preventive programs cost money upfront, but can cut programs cost money upfront, but can cut overall treatment costs to insurers by 30 overall treatment costs to insurers by 30 percent or more, yet few insurers pay for percent or more, yet few insurers pay for preventive care. A third of people with preventive care. A third of people with health coverage switch insurers every health coverage switch insurers every year, so insurers are reluctant to pay for year, so insurers are reluctant to pay for preventive health measures could become preventive health measures could become another company’s gain. another company’s gain.

The benefit of EHR adoptionThe benefit of EHR adoption

Studies predict a gain of as much as 30 Studies predict a gain of as much as 30 percent in efficiency from EHR use, mostly percent in efficiency from EHR use, mostly through reducing unnecessary tests and through reducing unnecessary tests and prescriptions, paperwork and medical prescriptions, paperwork and medical mistakes. In West Virginia, this amounts mistakes. In West Virginia, this amounts to a $3 billion savings (the total state to a $3 billion savings (the total state general revenue budget for 2007 was general revenue budget for 2007 was $3.629 billion) $3.629 billion)

The need for care coordination The need for care coordination and use of EHR:and use of EHR:

The average Medicare beneficiary has 15 The average Medicare beneficiary has 15 ambulatory care visits annually, with 6.4 ambulatory care visits annually, with 6.4 different health care providers and 20 different health care providers and 20 active prescriptions.active prescriptions.

A Medicare beneficiary with 5 or more A Medicare beneficiary with 5 or more chronic conditions has 37 visits annually, chronic conditions has 37 visits annually, with 13.8 distinct providers and 49 active with 13.8 distinct providers and 49 active prescriptions.prescriptions.

Lessons from West VirginiaLessons from West Virginia

Community health centers can be leaders in health Community health centers can be leaders in health improvement and EHR adoption;improvement and EHR adoption;Consider centralized networks to host EHR for Consider centralized networks to host EHR for economies of scale and public domain solutions;economies of scale and public domain solutions;There is no free EHR; payers need to help with cost There is no free EHR; payers need to help with cost since they reap benefit;since they reap benefit;Leverage health improvement, EHR alone is not a “silver Leverage health improvement, EHR alone is not a “silver bullet” to contain cost without system improvement;bullet” to contain cost without system improvement;Coordinate with Medicaid and consider using MITA Coordinate with Medicaid and consider using MITA funds to build and finance infrastructure (90% match);funds to build and finance infrastructure (90% match);Focus EHR acceleration and financing support at the Focus EHR acceleration and financing support at the primary care and community health level for greatest primary care and community health level for greatest ROI.ROI.

For more information, contact:For more information, contact:

David Campbell, CEODavid Campbell, CEOWest Virginia Primary Care Network, Inc., dba West Virginia Primary Care Network, Inc., dba

Community Health Network of West VirginiaCommunity Health Network of West Virginia500 Corporate Centre Drive, Suite 510500 Corporate Centre Drive, Suite 510

Scott Depot, WVScott Depot, WV 2556025560Email: david@chnwv.orgEmail: david@chnwv.org

Phone:Phone: (304) 201(304) 201--57005700or visit or visit www.chnwv.orgwww.chnwv.org