Transcript Title

Health Information
Technology
Citizen’s Health Care Working Group
Presented by
Scott D. Williams, M.D., M.P.H.
Vice-President, HealthInsight
July 22, 2005
1
Overview
• HealthInsight
 Medicare Quality Improvement Organization
(QIO) with CMS contract for Utah and Nevada
 DOQ-IT Project Pilot
• Promoting the use of Electronic Medical Records in
small and medium primary care physician offices
• Utah Health Information Network (UHIN)
 12 years of successful administrative health
data exchange
• Claims, remittance, eligibility
• Credentialing, coordination of benefits, EFT
 Regional Health Information Organization
development grantee (AHRQ)
• Labs, pharmacy, clinical notes and reports
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Issues in Health IT
• Value
• Who benefits &
who pays?
• Efficiency
• Outcomes
• Standards
• Self-regulated
• Externallyregulated
• Market driven
• Technology
• Architecture
• Hardware/ Software
• Connections
• Support
• Governance
• Community
interests
• Privacy, security
• Resource allocation
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Health IT: Applications
• Electronic Medical Record (EMR)
 Paperless office
 Personal Health Record
• Health Information Exchange (HIE)
 Regional Health Information Org. (RHIO)
 Allows interoperability between stakeholders
• Clinical Decision Support Systems (CDSS)
 Case and cohort management
 Computerized Physician Order Entry (CPOE)
 Prompts, recalls, trends, protocols, drug
interactions, generics, performance measures
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Value: Administrative Health Data
• UHIN (17 million claims/year)
 Efficiency of Claims Processing by 1 adjudicator
•
•
•
•
Paper
Scanned
EDI
Autoprocessing
100-150/ day
300/ day
700-800/ day
60% of claims require no
human involvement
 Payer value- just for intake of claim
• Paper = $6-10/ claim
• EDI < $1/ claim
 Provider value
• Faster payments
• Fewer rejected claims
• Less staff time
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Lessons Learned: UHIN
• Champion- credible, neutral, trusted
• Value accrues to all participants
Drives priorities
Drives business model
• Community ownership & governance
Consensus decision making
• Standards driven
• Use of data subject to governance
process
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Value: EMRs
EMR Adoption
Physician Offices
17%
Hospital ER
31%
Hospital Outpatient 29%
CDC March 2005
HIMSS, September 2004
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Value: EMR Adoption Barriers
among Physicians
• Initial Capital Cost
(345/423, ms = 1.85)
• Time Cost
(323/423, ms = 2.74)
• Confidentiality and
Security Concerns
(181/423, ms = 2.93)
• Maintenance cost
(300/423, ms = 3.00)
• Interfere with doctorpatient
communication
• Concerns about
learning new
technology
• Lack of technical
support
• Lack of control over
decision
• Lack of perceived
benefits
ms = mean score
Massachusetts Medical Society Survey Spring 2003
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Value: EMR Business Case for the
Physician
• Process efficiency (requires workflow redesign)
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Transcription
Forms
Telephone calls
Information collection from patients
• Lower overhead
 Fewer FTEs
 Less space needed for charts
• Increased reimbursement
 Better coding & recovery
 More patients seen (if workflow changes)
 Pay for Performance
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Value: EMR Business Case for the
Physician
Mean Benefit
Low End
High End
Savings (paperless,
capitated = 17%,
Fee for service = 83%)
$50,300
$21,800
$85,600
Costs, Year 1 (hardware,
software, inefficiency,
licenses, support,
updates)
$22,100
$13,700
$36,000
Costs, Year 2 +
$5,300
$2,600
$9,500
Total ROI, Year 1
$28,200
$8,000
$49,600
Total ROI, Year 2+
$45,000
$19,000
$76,100
Wang, S.J. et al. 2003
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Value: EMR Business Case for the
Physician
Wenner Georgia HIMSS Dec 2002
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Value: EMR Business Case for the
Physician
Wenner Georgia HIMSS Dec 2002
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Value: HIE
• Automation of clinical processes
• More timely, complete, accurate
patient information at point of
service
• Efficiency of connectivity
• Facilitate clinical decision support
systems across communities
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Value: HIE
• Missing Patient Data
 13.6% of primary care physician visits
 52% of missing data resides outside of system
 44% of data somewhat likely to adversely affect
patients
 60% of data likely to delay care or result in
additional services
 More likely among recent immigrants, new patients,
those with complex medical problems
 Less likely where physician has full EMR and also
in rural areas
Smith et al. JAMA. February 2005
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RHIOs: “Wiring” Healthcare
Efficiently
Current system fragments patient information
and creates redundant, inefficient efforts
Hospitals
Future system will consolidate information and
provide a foundation for unifying efforts
Hospitals
Public
health
Primary care
physician
Laboratory
Primary care
physician
Laboratory
Pharmacy
Pharmacy
Public
health
Health
Information
Exchange
Specialty
physician
Specialty
physician
Payors
Payors
Ambulatory
center (e.g.
imaging
centers)
Source: Indiana Health Information Exchange
Ambulatory
center (e.g.
imaging
centers)
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Value: HIE
• Based on published data and expert opinion
• Interoperability
 Level 2 = Fax
 Level 3 = Machine-organizable data
 Level 4 = Machine-interpretable data
• Net Value after full implementation
 Level 2 = $21.6 billion /year
 Level 3 = $23.9 billion/ year
 Level 4 = $77.8 billion/ year
• Costs: Benefit Calculation for Level 4
 Years 1-10 = $276 billion: $613 billion = $338 billion
 Year 11 + = $16.5 billion: $94.3 billion = $77.8 billion
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIE
• Contributions to the $94.3 billion benefit: Service categories
Laboratory testing
$31.8 billion
Imaging
$26.2 billion
Provider-payer transactions
$20.1 billion
Chart transfers between providers
$13.2 billion
Pharmacy
$2.71 billion
Public health reporting
$195 million
• Contributions to the $16.5 billion cost
Clinical office system cost
$9.08 billion
Hospital system cost
$1.58 billion
Provider interface cost
$5.40 billion
Stakeholder interface cost
$467 million
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIE
•Where does $77.8 billion net value accrue (HIE Only)?
Providers
$33.7 billion
Payers
$27.6 billion
Laboratories
$13.1 billion
Radiology centers
$8.2 billion
Pharmacies
$1.3 billion
Public health departments
$94 million
Walker et al. Health Affairs. January 2005
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Value: Level 4 HIE
• 50-200 Bed Hospital
$2.7 million in IT investment
$250,000/year in maintenance
$1.3 million/year in transaction savings
•
•
•
•
•
$570,000 from other providers
$200,000 from other laboratories
$170,000 from radiology centers
$250,000 from payers
$70,000 from pharmacies
Walker et al. Health Affairs. January 2005
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HIE: UHIN Approach
• Identify value-based priority use
cases with interested stakeholders
• Obtain broader stakeholder support
• Develop and adopt technical model
• Develop and adopt financing model
• Convene standards development
process
• Adopt standards
• Pilot, refine, implement
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Value: CDSS
Practice Variation
“...risk-adjusted cost varied almost 3-fold...”
Duke Clinical Research Institute 2002
“...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
30%
70%
“...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.
Project Hope, Wennberg et.al., 2003/HealthAlliant
Annual U.S. health care expenditures:
$1.7 trillion x 30% = ~ $500 billion
“...30% of direct health care outlays are
the result of poor-quality care...”
MBGH, Juran, et al 2002
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Value: CDSS
CPOE
•
•
CDSS
25% improvement in ordering of
•
corollary medications by faculty
and residents (p<0.0001) Overhage,
1997
55% decrease in non-intercepted
serious medication errors (p=0.01)
Bates, 1999
•
81% decrease in medication errors
(p<0.0001) Bates, 1999
•
Improvement in 5 prescribing
practices (p<0.001) Teich, 2000
6 of 14 studies showed
improvement in patient
outcomes. Hunt 1998
•
43 of 65 studies showed
improvement in physician
performance. Hunt 1998
•
17% improvement in antibiotic
regimen suggested by computer
consultant versus physicians
(p<0.001) Evans 1994
•
70% decrease in adverse drug
events caused by anti-infectives
(p=0.02) Evans 1998
Source: Center for Information Technology Leadership, 2003
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Value: CDSS
100%
Medical Knowledge
Treatment
50% of Cost
20% of Return
Diagnostic
Redundancy
Patient Data
Errors
EMR
Source: SBCCDE, CITL, Gordian Project analysis
HIE
CDSS
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Value: Outpatient CPOE
• Savings from nationwide adoption
Adverse Drug Reactions = $2 billion
• Eliminate 2 million adverse drug reactions
• Eliminate 190,000 hospitalizations
Medication management = $27 billion
Radiology management = $10.4 billion
Laboratory management = $4.7 billion
Total = $44 billion
Source: Center for Information Technology Leadership, 2003
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Value: Who benefits?
Who Pays?
% of Savings Captured by
Private Payers
Medicare
Medicaid
89%
11%
Physicians
Self-insured
Self-pay
Ambulatory Computer-based Physician Order Entry
Source: Center for Information Technology Leadership, 2003
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Health IT: Federal Government Roles
• Facilitate the implementation of a national
strategy
• Support innovation experiments
• Confirm business value and align incentives
• Coordinate the implementation strategies of
federal health care agencies
• Assure the rapid development of data and
technical standards with broad input
• Assure that privacy and security regulations
don’t encumber interstate health data exchange
• Incentivize health IT savings to be redirected into
effective health care interventions
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