Transcript Priorities in Safety, Quality & Performance

Health Information Technology & Quality:
A Lesson from the Past, Promise for the Future
Health Care Industry:
When Consumer Expectations Collide With Cost
Dorsey Hughes Symposium - Colorado Health Foundation
Beaver Creek, CO – July 28, 2007
Jonathan B. Perlin, MD, PhD, MSHA, FACP
Chief Medical Officer & Senior Vice President – Quality
HCA / Hospital Corporation of America
Nashville, TN
•
“98,000 Hospital
Patients Die Yearly
Because of Adverse
Events”
–
(IOM, 1999)
•
“Virtually Every Patient
Experiences a Gap
Between the Best
Evidence and the Care
They Receive”
–
(IOM, 2001)
•
“A Hospital Patient Can
Expect on Average to be
Subjected to More than
One Medication Error
per Day”
–
(IOM, 2006)
Poor Quality & Breaches of Safety
are not a Good Business Case
Quality is the Best Business Case
•
•
Safety – is Fundamental
– Goal: Avoid Getting It Wrong
Effectiveness – To Close to Chasm
– Expect effectiveness in maintaining & improving health,
managing disease & distress
To Err is Human:
98,000 Patients
– Goal: Getting It Right . . . Consistently
•
Efficiency:
– Goal: Reduce waste; Use resources for maximal benefit
•
•
Compassionate (Patient-Centered, Coordinated) Care
– Patient (or lay caregiver) is empowered
– Seamless across environments
– Seamless across health & disease(s)
– Anticipates needs, rather than just reacting to them
The Quality Chasm:
Every Patient
“Crossing the Quality Chasm” 2001: IOM
Goal: Safe, Effective, Efficient & Compassionate Care
– Litmus Test: Without the need for an advocate
•
Consumer Expectations & Costs Should Be Compatible!
July 15
3
VA – 1996
 A Lot of Question Marks:
 Information Discontinuity
 Paper Charts (available 60%)
 No Performance Measurement
 Baseline Performance Assessed 1996
 24 – 55% basic guideline compliance
4
1996: A Visit to VA
 65 y.o. WM to VA
 PMH:




Diabetes
Htn
CAD; s/p MI 1990, CABG 1990
Habits: 35 pk-yr smoker; 1 pk/d
 FHx: CAD (F †MI 54 yo)
 Meds:
 Nifedipine (dose?)
 Allergies: ?
 Preventive Health:
 Flu Vax: No, Pneumo: No
 Cancer Screens ?
 Tobacco / Substance Screens & Counseling ?
5
VA Performance, c. 1996
VHA - Earliest Date Measures
Date Measured (earliest recorded
measurement period)
Colorectal cancer screening
34%
FY 96 Qtr 5
LDL Cholesterol < 100 after AMI, PTCA, CABG
42%
FY 99(after AMI Only)
LDL Cholesterol < 130 after AMI, PTCA, CABG
76%
FY 98 (after AMI Only)
Beta blocker on discharge after AMI
70%
FY 96 Qtr 4
Diabetes: HgbA1c done past year
51%
FY 96 Qtr 4
Diabetes: Poor control HbA1c > 9.0% (lower is better)
24%
FY 01 (FY 99 was <9.5 = 77%)
Diabetes: Cholesterol (LDL-C) Screening
47%
FY 97 Qtr 4
Diabetes: Cholesterol (LDL-C) controlled (<100)
36%
FY 01 New Baseline
Diabetes: Cholesterol (LDL-C) controlled (<130)
68%
FY 98 Qtr4
Diabetes: Eye Exam
46%
FY 96 Qtr 4
Diabetes: Renal Exam
23%
FY 97 Qtr 4
Hypertension: BP <= 140/90 most recent visit
45%
FY 98
Follow-up after Hospitalization for Mental Illness (30
days)
81%
FY 99
Immunizations: influenza, (note patients age groups)
27%
FY 96 Qtr 4 (includes high risk < 65)
Immunizations: pneumococcal, patients 65 and older
26%
FY 96 Qtr 4 (includes high risk < 65)
Tobacco Cessation Counseling
33%
FY1996
CLINICAL PERFORMANCE INDICATOR
6
The Patient Experience –
“Behind the Scenes - 1996”
 Patient Appointments & Medical Records in
the Paper World . . .
 Patient Appointment is Scheduled
 Unit Clerk Calls to Request Medical
Records on day of Appointment
 Patients “chart” put into delivery queue
 New labs or consultation comes in
 Data to “Loose Filing” (measured in linear feet)
 Patient seen at another VA site (e.g., ER)
 Data will be sent by mail or courier (to loose
filing), including record of new prescription . . .
 Medical Records sends chart on night
before or day of care
 Patient Reschedules Appointment for next day
 Chart en route back to Medical Records . . .
7
A Quality – Value Framework for
Performance . . .
Value
•
=
QUALITY
Value
Cost
=
OUTCOMES
Cost
VHA “Value Domains”
1.
2.
3.
Quality
Access
Satisfaction
Value =
4.
5.
6.
Functional Status
Community Health
Cost-Effectiveness
Access + Technical + Functional + Satisfaction + Community Health
Cost
1. QUALITY: RAND Study - Asch, McGlynn et al
Annals of Internal Medicine 2004;141:938-945
VHA scored significantly
higher across 294 comparable
quality metrics”
July 15
9
“ . . . Patients from the VHA shored
significantly higher for adjusted
overall quality”
July 15
10
5. COMMUNITY HEALTH: Hurricane Katrina Relief
• New Orleans VA
Patients did not lose their
medical records, even
when they lost their
City
• Their Electronic
Health Records
followed them
around the USA!
• VA Mobile Clinics served
Veterans & Community
July 15
11
Building Quality & Value
and Building the Legend . . .
2006: A Visit to VA
 65 y.o. WM to VA
 PMH:




Diabetes
Htn
CAD; s/p MI 2003, DE-Stents 2003
Habits: 35 pk-yr smoker; 1 pk/d
 (84% Counseled X 3; >99% X1)
 FHx: CAD (F †MI 54 yo)
 Meds:
 ASA (>99%), B-Blk (>98%), ACE
 Allergies: NKDA (~100%)
13
2006: A Visit to VA
 Preventive Health / Disease Management:
 Flu Vax: Yes (81%), Pneumo: Yes (94%)
 HTN (74% < 140/90 )
 DM




A1c > 9 or not checked (<13%)
Retinal Exam (73%)
Monofilament Sensory Test Foot (83%)
LDL < 120 (81%)
 CAD
 Tobacco Screening (>99% x1; 82% x3)
 3x national rate cessation
 Current use 27% VA - vs 33% Military*, 22.5% US)
* Varies by service & rank
 Other
 CRC CA Screening (74%), Prostate CA Counseling
 NB. EHR Available 100% (99.3875%)
14
VA’s Electronic Health Record
Every medical center has
the Computerized Patient
Record System . . .
Cost - $90 / pt / yr
Bar-Coded Medication
Administration


5.85 Sigma Performance
Helped hold per prescription costs virtually constant for 5 years (~2½% / year)
Medical Records Today . . .
Wagner Model of Chronic Care:
A Conceptual Framework
Community
Self-management
Support
Informed,
Activated
Patient
Health System
Decision
Support
Delivery
System
Design
Productive
Interaction
Clinical
Information
System
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
17
Model for Care Coordination
Optimal Population Outcomes
Community
Self-management
Support
Informed,
Activated
Patient
Health System
Decision
Support
Delivery
System
Design
Productive
Interaction
Clinical
Information
System
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
18
Model for Care Coordination
Optimal Population Outcomes
Community
Self-management
Support
Informed,
Activated
Patient
Health System
Decision
Support
Delivery
System
Design
Productive
Interaction
Clinical
Information
System
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
19
From Evidence to Practice…
Reduce Quality Chasm
Possess Operationalize
Knowledge Patient
Patient Knowledge
Need
With
Measurement
Pneumococcal
Met
Need
Framework
Pneumonia
Vaccination
Indications
+
Supporting
Technologies
Computerized
Health Information
System
+
Accountability

System Changes
Clinical Reminders for Decision-Support
Contemporary
Expression of
Practice Guidelines
• Time &
Context
Sensitive
• Reduce
Negative
Variation
• Create
Standard Data
• Acquire
health data
beyond care
delivered in VA
Operationalizing Knowledge through the EHR
- Pneumonia Vaccination Rate Improvement in VA
Percent Vaccinated
100
80
--BRFSS 90th--
60
--BRFSS--
40
20
0
FY 95
4th
4th FY 99 FY 00
Qtr 97 Qtr 98
VHA
CHG FY01* FY02
Healthy People 2000
Iowa 99*
FY03
FY04
NHIS
•Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz
•HHS: National Health Interview Survey, >64
FY05
Pneumonia: Acute Inpatient
DRG89-90
VHA Data - Unadjusted
9,500 fewer
bed days
8,000 fewer
discharges
FY1999
Acute Days
FY2000
106
104
102
100
98
96
94
92
90
88
FY2001
Discharges
Total Days (bedsection)
16.2
16
15.8
15.6
15.4
15.2
15
14.8
14.6
Thousands
Thousands
Total Discharges (bedsection)
Despite doubling patient population, halved hospitalizations for pneumonia!
Increased Rates of Pneumococcal Vaccination have saved
over 6,000 lives, just among Veterans with Emphysema !
Extrapolated from K Nichols et al
July 15
24
CPOE: ~94%
Exceptions:
- Verbal
- Protocol
25
Bar-Coded Medication
Administration (BCMA)
BCMA Assures:
• Right Medication
• Right Patient
• Right Dose
• Right Route
• Right Time
Virtually Eliminates Errors at the Point of Administration
• Installed in ~15% Hospitals Nationally (VA & HCA)
. . . Coming Soon: Bar-Coded Lab Acquisition
26
July 15
27
Why has the President made Health IT a National Strategy?
Healthcare in the U.S., presents Multiple Challenges . . .
•
Information:
– 12% of physician orders are not
executed as written*
– 20% of laboratory tests are
requested because previous
studies are not accessible.*
– 1 in 6.5 hospitalizations
complicated by drug error**
• 1 in 20 outpatient prescriptions**
– 1 in 7 hospitalizations occur
because previous records not
available*
* PITAC (President’s Information Technology
Advisory Committee, 2004)
** Bates & Leape, multiple references
•
Effectiveness:
– Safety Gap: 98,000 Americans die each
year from medical errors
– Quality Gap: Virtually every patient
experiences a gap in care from best
evidence / most effective
– Compassion Gap: Not Patient-Focused
•
Efficiency:
– Value Gap: Health care inflation
• Inferior outcomes per dollar
– 31% Waste Estimated (Woolhandler, O’Neill)
• Un-insurance / Under-insurance
– American health care is reactive, not
preventive, predictive
– Patients / Payors (Govt) / Providers
increasingly concerned about Value
• Competitiveness
Limited Information → Limited Safety, Quality, Efficiency, Service, Value
July 15
28
Effect of Entitlements on Federal Budget:
Social Security and Medicare’s Hospital Insurance
Trust Funds Face Cash Deficits
200 Billions of 2006 dollars
100
0
Social Security
cash deficit
2017
-100
Medicare HI
cash deficit
2006
-200
-300
-400
-500
-600
-700
-800
-900
2005
2010
2015
Medicare HI cash flow
2020
2025
2030
2035
2040
Social Security cash flow
Source: GAO analysis based on data from the Office of the Chief Actuary, Social Security Administration and
Office of the Actuary, Centers for Medicare and Medicaid Services.
Note:
Projections based on the intermediate assumptions of the 2006 Trustees’ Reports. The CPI is used to
July 15
adjust from current to constant dollars.
29
48%
42%
(Figures represent percentage
of gross domestic product)
36%
30%
All Other
Spending
24%
Net
Interest
18%
12%
Medicare &
Medicaid
REVENUE
6%
Social
Security
0%
2003
2006
2009
Source: GAO Simulation of Future Budget Trends
July 15
2012
2015
2018
2021
2024
2027
2030
2033
2036
2039
As reported in “Government Executive” February 2005 issue.
30
Medicare is Unsustainable in its Present Form: Historical and
Projected Number of Medicare Beneficiaries and Number of Workers
Per Beneficiary
Number of beneficiaries
(in millions)
50
Services per 1,000 beneficiaries served
3,
45
43
43
42
42
41
4,000
43
3
3,
53
9
3,
63
0
3,
67
2
3,
77
4
3,
92
5
Percentage of beneficiaries receiving services
Number of workers
per HI beneficiary
78.6
40
3,000
30
2000
2000
2001
2001
2002
2003
20
3.9
3.7
2002
2,000
2003
2004
2004
2005
2005
61.6
1,000
10
0
4.0
2.9
0
42.7
2.4
46.5
39.7
2000
2006
2010
2020
2030
2000
2006
2010
2020
2030
Source: 2001 and 2006 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal
Supplementary Medical Insurance Trust Funds.
July 15
31
Information Links Care . . .
And Challenge Becomes Opportunity
July 15
32
Model for Care Coordination
Optimal Population Outcomes
Community
Self-management
Support
Informed,
Activated
Anticipated
Patient
Health System
Decision
Support
Delivery
System
Design
Productive
Interaction
Clinical
Information
System
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
33
My Health eVet
 Internet-based, secure Personal Health Record.
 (Available) Personalized Health Assessments
 (Available) View, retain, and update their personal Health
Data (BP, Blood Sugar, Wt, etc.)
 (Available) Comprehensive, Personalized Health
Education & Information
 (2006) Provides veterans with copies of key parts of their
own VA Health Record
 Activate & Empower Patients as (responsible)
partners with health care providers in achieving
optimal health, through the sharing of actionable
health information
34
35
36
37
“Hey, Doc,
I have Heart Failure,
Shouldn’t I be on an ACE
Inhibitor ?”
38
PERSONAL HEALTH
Supporting
CARE COORDINATION
Care Coordinator
Becomes Aware that the
Patient Is Beginning to
“Get Into Trouble,”
Proactively, The Patient
Is Called To Come Into
Clinic . . .
Or Visited at Home!
Before S/He “Crashes”
July 15
39
Remote Physiological Monitoring
New Knowledge as a Transparent By-Product of Care
From “TRIP” (Translating Research into Practice) to
“TPIR” (Translating Practice into Research)
Research
Knowledge
Management
Practice
Discovery: Seasonal Variation in Blood Pressure
Hypertensive Patients Returning to < 140 / < 90
Latest BP in the last 6 months (n=10,000 patients)
Percent Patients
55
50
45
40
35
30
Sep-98
Mar-99
Sep-99
Mar-00
Sep-00
Mar-01
Sep-01
Mar-02
Sep-02
Courtesy of Dr. Ross Fletcher, Washington, DC VAMC
42
Adjusted Odds Ratios for Mortality (2002-05) in VA ICU’s
Mean Glucose is Independently Associated
with Increased Mortality
Odds Ratio (95% CI)
Mean Glucose (mg/dl)
111-145
146-199
200-300
> 300
Entire
cohort
1.3 (1.2-1.3)
1.7 (1.6-1.8)
2.0 (1.9-2.1)
2.6 (2.3-2.9)
No DM
1.3 (1.2-1.4)
1.9 (1.8-2.0)
2.7 (2.4-2.9)
3.8 (3.1-4.6)
+ DM
1.1 (1.0-1.3)
1.4 (1.2-1.6)
1.8 (1.5-2.0)
2.4 (2.0-2.9)
The Promise of Personalized Medicine . . .
• What is Personalized Medicine
– Treating the patient’s unique disease,
not diseases like the patients . . .
- Biomarkers & Predicting Disease Response
- Requires Large Data Sets (ie, VA, HCA, KP)
- eg., GMU Cancer Study
• What is Genomic Medicine (GM)?
– Relates a person’s clinical characteristics to
his or her genetic characteristics
– GM offers the possibility of truly “personalized”
health care
• Tailored Medications, Interventions, Imaging
– Naltrexone Sensitivity in Alcohol Abuse
– Pediatric Leukemia
– CYP & Metabolism
July 15
http://www.gehealthcare.com/inen/rad/nm_pet/p
roducts/pet_sys/lscasehypolaryngeal.html
44
ONCHIT (Office of the National Coordinator for Health Information Technology)
AHIC
(American Health Information Community)
HITSP
“ . . . Standards
Harmonization Use Cases
focus on the American
Health Information
Community (AHIC)
breakthrough areas to
enable interoperability
among different information
systems, software
applications and networks
to communicate and
exchange information in an
accurate, effective, useful
and consistent manner.”
http://www.ansi.org/standards_activities/standards_boards_
panels/hisb/hitsp.aspx?menuid=3#Document
Certification Commission for Health Information Technology
• Mission: “. . .to accelerate the adoption of health information technology by
creating an efficient, credible and sustainable product certification program”
• Criteria Development: Use an open, consensus-based process with
multiple rounds of public comment to set criteria for:
– Functionality, Interoperability, Security
• History: Founded as voluntary private-sector organization to certify HIT
products by:
– AHIMA (American Health Information Management Association)
– HIMSS (Healthcare Information and Management Systems Society)
– Alliance (National Alliance for Health Information Technology)
• In 2005, HHS awarded CCHIT a three-year contract to develop and evaluate
certification criteria and create an inspection process for HIT in three areas:
– Ambulatory EHRs for the office-based physician or provider
– Inpatient EHRs for hospitals and health systems
– Network components through which they interoperate and share information
• CCHIT Chair – Dr. Mark Leavitt
© 2007 | Slide 48 |
Four Ways Certification Can Accelerate
EHR Adoption
• Reduce the risks of investment in EHR/EMR
products
• Facilitate interoperability of EHR products with
emerging health information networks
• Enhance availability of EHR adoption incentives
and relief of regulatory barriers
• Ensure that EHR products and networks always
protect the privacy of personal health information
© 2007 | Slide 49 |
Incentives: Federal Payers & Health IT Rationale
Increasing reporting requirements and measures
– Current Status: Pay for Submission of Data (“RHQDAPU”)
•
Measures are “voluntary,” however, non-participation results in forfeiture of 2% annual market basket
update.
– Future Status: Pay for Performance to Non-Pay for Non-Performance
•
Deficit Reduction Act (DRA) of 2005 authorizes CMS to develop value-based purchasing for Medicare hospital
services to be implemented in October 2008
– Proposal: Payment will be based on performance
• Failure to hit attainment threshold results in receipt of no incentive dollars
• Rapid expansion of current measure sets to include outcome and efficiency measures
– Current 21 CMS Hospital Quality Alliance (HQA) measures with 106 data elements
» Significant workload in parsing by nursing unit, provider, etc.
» Current processes of data collection are largely manual, collateral duties
» CMS measures expand to 35 in 2008
– Move to Revise DRG’s
•
NB: Proposed 2008 Inpatient Rule recommends expanding current 538 to 745 Medicare Severity-adjusted
DRG’s (MS-DRG)
– Present on Admission (POA) Indicator; no “CC payment” if
MRSA present
EHR use will become a measure, likely a “condition of participation” (COP)
– 2008 Measures will include structural measures such as the use of electronic prescribing.
– 2009 Measures will include episode-of-illness, not just episode-of-care
What an Insurer Sees: Cost & Quality of Care for Medicare Patients Hospitalized
for AMI, Colon Cancer, and Hip Fracture, by Hospital Referral Regions, 2000-2002
Quality of Care*
(1 Year Survival Index, Median = 70%)
1.20
Median Relative Resource Use = $25,994
1.10
1.00
0.90
0.80
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
Relative Resource Use**
*Indexed to risk-adjusted 1 year survival rate (median= 0.70)
**Risk-adjusted spending on hospital and physician services using standardized national prices
Data: E. Fisher and D. Staiger, Dartmouth analysis of data from a 20% national sample of Medicare beneficiaries
SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
51
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Incentives: Private Payers & Health IT Rationale
Trends & Trajectory
Value-Based Purchasing (VBP) – Buying Outcomes, not Units-of-Service
–
Systematic purchase of best measured performance at lowest cost for appropriate indications
“Employerism” Trumps Consumerism
–
Employers (e.g., WalMart), increasingly concerned with health costs exerting interest in Value-Based Purchasing,
often directly and through “preferred provider” networks
Insurers
–
–
United Health and Anthem/WellPoint now cover 1in 4 (privately insured) lives
In some HCA markets, concentration is much greater ( e.g., Las Vegas, United covers 80% commercial, 99%
managed Medicare)
Implications:
(1) Increasingly, Tier and Steer”
–
Differential Co-Pay for Beneficiaries based on provider choices
•
–
–
E.G., 10% for Tier 1, 20% for Tier 2, 30% for Tier Three
Differential premiums for employers, based on utilization choices
Differential ratings for referring physicians, based on utilization choices
(2) Private Payers Increasingly Require Measurement for Participation in Network
–
–
Participation in United Health Premium® cardiac contract requires clinical performance measures; similar initiative in
oncology, orthopedic, women's and child health, etc.
Anthem’s QHIP program does not list lower performers (though not presently excluded from network, not visible to
employers, patients, or providers
Therefore, Performance = Volume = Revenue
Increasingly Unique Data Demands Will Favor
Organizations with Ready Access to Clinical Data
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Growth: EHRs Enhance Physician Affinity
( “But patients go where their doctor practices / refers…” )
Physicians trained with EHR exposure (65%) are making affiliation decisions
based on EHR availability
–
Harris Interactive Poll (Testimony to HHS):
•
•
Physicians Under 35 choosing not to affiliate with systems without EHR
Physicians 35-45 prefer systems with EHR
Physician Pay For Performance (P4P) requires data support
–
Physicians increasingly asking for data to support their
•
•
•
Success under P4P
Maintenance of Board Certification
Maintenance (or achievement of) “premium provider” status
Patients go where
–
–
they are insured
their physicians send them
Physicians refer
–
–
where they like to practice
where their profile is positively affected
Patients = Volume = Revenue
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The Physician Information System
Handheld
Tablet/Browser
•
Provides a common physician interface
to all relevant data – regardless of the
source system or organization
•
Automates the “Day in the Life” of a
physician with robust workflow
applications
•
Accessible anywhere anytime via
desktops, laptops, tablets,
smartphones, and/or PDAs
•
Connects to multiple source systems
within and across organizational
boundaries
•
Enables expansion and configuration
without end user impact
HCA Trajectory
Clinic
Hospital A
Hospital B
Physician
Practice
55
55
From Industrial Age to an Information
Age Model . . .
• Industrial Age:
– Care is centralized,
fragmented & discontinuous
• Provider-Centric
– Patient must negotiate
system
– Knowledge vested in provider
(almost) exclusively
• Memory: Try to Know
Everything
– Knowledge development done
mostly by researchers
– Mass Production
• Productivity is best evidence
applied consistently
– Population Guideline
July 15
• Information Age:
– Care is decentralized;
information supports continuity
• Patient-Centric
– System provides context to
support patient over time, place
– Knowledge accessible to
professionals & patients
• Skill: Know how to find /
evaluate information on anything
– Knowledge development
increasingly a by-product of care
– Mass Customization
• Productivity is best evidence
applied uniquely
– Personalized Health Care
56