Health IT Enabled Solutions to Support Accountable Care and Non-Volume Based Payment: What’s Needed; What’s Available; and What’s Missing?

4th Annual National ACO Summit – June 13, 2013

Peter Basch, MD, FACPMedical Director, MedStar Million HeartsMedical Director, Ambulatory EHR and Health IT PolicyMedStar Health

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About me• General internist, daily EHR user• Medical Director for Ambulatory EHR and Health IT

Policy, MedStar Health• Visiting Scholar, Engelberg Center for Healthcare

Reform, Brookings Institution• Senior Fellow in Health IT Policy, the Center for

American Progress• Chair, Medical Informatics Committee, American College

of Physicians

Disclaimer – while much of what I am discussing today may be consistent with formal positions taken by MedStar Health, the Engelberg Center, the Center for American Progress, or the American College of Physicians… I am here today speaking as an individual 2

Session Agenda

• Brief overview of (1) health IT components necessary to improve health and healthcare delivery (and are in alignment with a payment model that is not strictly volume-based); and (2) other necessary co-factors

• Panel presentation and discussion– On the ground challenges – Improving shared decision making and reducing

unnecessary care– Achieving real patient engagement– How a health system is putting this all together

• Interactive discussion and Q&A3

While We Will Be Primarily Describing Health IT Components – Their Value Is Only Consistently Demonstrated When They Work Well And Are Consistently Used

Necessary co-factors•Implementation and training•Continued maturity / improvement of components and connectivity•How it’s used (thoughtful workflow redesign)•What drives its optimized use and improvement (payment model) 4

Effect of Healthcare Payment System on Health IT Maturation and Use?

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http://www.americanprogress.org/wp‐

content/uploads/issues/2009/05/pdf/health_it.pdf

Aspects of Health and Healthcare Delivery that Could Benefit from Health IT Solutions

Patients / Caregivers•Lack of information•Lack of connectivity to sources of care•Access to care•Useful and usable information to best manage care and costs

Providers•Lack of appropriate information, in context, with rules, applied to the individual, updated with new evidence•Integrated with patient preference•And payer rules•Supporting warranted variability and limiting unwarranted variability•Administrative burden and complexity – relief from unnecessary process friction•Measurement and feedback

Health System•Sophisticated analytics•Risk assessment and management•Patient tracking and support

System•Assembly of sources of information•Interoperability

Key Attributes for Success•Transparency of information and rules•Reasonableness of rules•Transparency and reasonableness of measures•Ability to reasonably act on information and rules

June 3, 2013

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Three Examples of Available / Emerging Health IT Components in Support of Value

• eFormulary – managing pharmacy spend• Diagnosis-based order sets – managing use of

laboratory, radiology, other services• Million Hearts® - a program to systemically

reduce cardiovascular risk– Information, information presentation– Incorporation of evidence-based rules– Allowing for warranted variability; limiting unwarranted

variability– Shared decision making– Patient engagement and activation

June 3, 2013

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eFormulary – Managing Pharmacy Spend

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Diagnosis Based Order Set – Managing Laboratory Services

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Million Hearts®: A Public – Private Partnership to Prevent 1 Million Heart Attacks and Strokes over 5 Years

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Premise of Million Hearts – Improve the ‘ABCS’ of Modifiable Cardiovascular Risk

Modifiable Risk 2012 National Baseline 2017 Clinical Target

Aspirin use for Primary 

Prevention of MI/Stroke

47% 70%

BP –

screen and control 46% 70%

Cholesterol – screen and 

control

33% 70%

Smoking ‐

cessation 21%  current smokers ↓ by 10% (19%)

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• Achieving 2017 clinical targets nationwide will reduce the 

~2M new heart attacks and stroke each year by 10%• Over 5 years – 1M new heart attacks and strokes prevented • Cost savings = ~$30‐45B/year

Early in 2012 – MedStar Health Became the First Private Partner with Million Hearts®

Modifiable Risk 2012 MedStar

Baseline 2017 Clinical Target

Aspirin use for Primary 

Prevention of MI/Stroke

? 70%+

BP –

screen and control ? 70%+

Cholesterol – screen and 

control

? 70%+

Smoking ‐

cessation 13.25%  current smokers ↓ by 10%+ (11.9%)

June 3, 2013

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• Our 2012 baseline for Aspirin use for primary prevention, BP 

at goal and Cholesterol at goal –

never previously reported 

on –

thus no clear baseline

MedStar Million Hearts®: A Clinical Program to Provide Consistently Better CV Care for our Primary Care Patients

• All MedStar primary care sites will have information available about Million Hearts® and MedStar's partnership efforts.

• Every adult patient who receives care from a MedStar primary care provider will be appropriately screened for high blood pressure and high cholesterol and will also be encouraged to discuss Million Hearts® with their PCP and have their cardiac risk assessed.

• Every adult patient who should be on aspirin (without allergy or contraindication ) will be encouraged to take aspirin.

• Every adult patient will have evidence-based goals set for their BP and cholesterol results; those with elevated BP and/or cholesterol will be optimally treated towards those goals.

• Every adult patient will be assessed for smoking, and if they smoke, they will be optimally managed towards cessation.

• Every adult patient will be provided with an individualized end-of-visit summary – showing their current ABCs “report card,” and reasonable steps they could take to further reduce their risk of heart disease and stroke.

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Leveraging the EHR to Make Awareness and Adherence to the “ABCS” Easier…

• Form that opens in the background of all adult medicine visits

• Auto-calculates risks and goals

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Improving Information, Context, Rules, Display, and Actionability…• ‘ABCs’ prompts

show protocol AND relevant prior information in the EHR

• The prompts also contain most all reasonable actions – adding / changing meds, creating referrals, etc. Checkbox choices also create documentation in the note AND structured data for future analysis and reporting.

June 3, 2013

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Example of the Prompt Cascade – When All of the ‘ABCS’ Goals are Unmet

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So Why Do I Still Feel Like This?

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eFormularies Don’t Really Work

• Formularies are still not much more accurate paper plan-level

• Display of “alternatives available” does not only reflect “less costly alternatives available”

• Alternatives are poorly labeled or mislabeled

• Least costly alternatives not clear (to whom) – to plan, to patient 18

Diagnosis Based Order Sets

• Mostly not risk adjusted• Often do not act on patient data outside the

provider EHR• Difficult to create rules that fit the reality of actual

patient care and coverage rules

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MedStar Million Hearts®

• In spite of complexity and time burden to every primary care visit – good buy in from leadership and providers

• Currently no payment model to support it – erosion of good results as novelty of program wears off

• Unintended consequence of total provider buy- in; closer look at– Algorithms and rules – which are not quite right when

automated into the EHR– Quality measures not quite right 20

Wasted Money and Effort on Administrative Complexity / Process Friction

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Our Panelists

Ted Meisel Marc Overhage Elevation Partners Siemens Healthcare

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Jordan Shlain Earl Steinberg HealthLoop Geisinger Health System