Transcript Gold - Technology - Jefferson Digital Commons

Improving the Quality and Efficiency of
Care with Technology
Anthony Gold
July 22, 2010
www.healthyhumans.com
The Challenges
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Chronic illness trends
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Medical "errors"
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133 million, >1%++ by 2030
50% with co-morbidities
78% of healthcare costs (~$1 trillion)
45K-98K annual deaths
$17 billion (direct medical costs)
Satisfaction
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PCP shortages and decline in physician hours
Decline in quality of physician-patient interaction
Non PCP-friendly comp & reimbursement models
Long patient wait times, decreased physician accessibility
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The Players
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Patients
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Providers
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Hospitals
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Insurers
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Pharmaceutical companies
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Employers
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Federal / State / Local agencies – Policy makers
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Can Healthcare IT Solve All That?
HARDLY!
But it can help.
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Technology Elements
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Patient record
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Decision support (CPOE)
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Secure messaging
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eRx
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eScheduling
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eLabs
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Tracking/Alerts (eLabs 2.0)
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Self-care
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Workflow optimization
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Patient Reminders
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Population Registry
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Healthcare IT Value Tenets
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Patient Safety
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Quality of Care
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Patient Access & Satisfaction
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Productivity of Physician & Staff
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Satisfaction of Physician & Staff
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Cost optimization
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Revenue enhancement
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Patient Record
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Electronic storage of key patient data:
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Demographics
Insurance info
Medical history
Diagnosis history
Medications
Allergies
Immunizations
Office notes w/ basic diagnostics (weight, b/p, etc.)
Document storage (lab results, secure messages, etc.)
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Archived & Searchable
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Reduced documentation and storage
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Big challenge: Getting started
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Decision Support
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Computerized physician order-entry (CPOE)
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Avoiding drug-to-allergy contraindications
Proper medication dosage (age, weight, lab results, etc.)
Proper form of medication administration
Avoiding drug-to-diagnosis contraindications
Handling drug-to-drug relationships
Avoiding duplicate medications
Requires decision support "infrastructure"
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Database of existing patient data (meds, allergies, etc.)
Availability and commitment of staff
Human to review warnings
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Secure Messaging
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Like email, but:
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Enhance communication AND collaboration across "eco-system"
of health
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Secure
Rules-based
Work-flow processes
Part of patient chart
Patients (and loved ones)
Providers (PCPs, Specialists, RNs, PAs, etc.)
Hospitals
90% of Internet users would like this ability
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Secure Messaging
When do patients use it?
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Discuss changes in a health condition
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Ask questions about lab results
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Describe new condition
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Request drug dosage adjustments
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Request a new (or refill) prescription
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Secure Messaging
Does it really make a difference?
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7-10% less likely to schedule an office visit
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14% less likely to contact physician by phone
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Enables patients to follow medical instructions "to the letter"
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Eliminates "phone tag"
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2.0-6.5% improvement in diabetic, hypertensive patients
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Blood sugar
Cholesterol
Blood pressure
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Electronic Prescriptions (eRx)
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Works with most retail and mail-order pharmacies
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Very easy (and inexpensive) to setup
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Reduces documentation errors
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Can reduce clinical errors (CPOE)
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Stored as part of patient record
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Patient requested refills (reduce office calls, and Top 4 request
of "online" patients)
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Electronic Scheduling (eScheduling)
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Requesting vs. Schedule Blocking
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Reduces office calls
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Reduces serialized scheduling --> can lead to greater efficiency
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Top 4 request amongst "online" patients
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Tied to appointment reminders
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Electronic Labs (eLabs)
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Electronic request to lab (no paper) and electronic receipt of
results from lab (no paper)
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Most labs support electronic xfer (Quest, Labcorp,
BioReference, CLM, Lenco, Sunrise, etc.)
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Fairly simple and inexpensive to setup
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Stored automatically into patient record
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Including triggering of alert messages
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Easy sharing with other providers (and patient)
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Top 4 request amongst "online" patients
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eLabs 2.0 (Tracking & Alerts)
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Capture diagnostic data from patient
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Track patient while "outside" of physician's office
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Phase 1: Manual entry
Phase 2: Digital (ie bluetooth) capture
Typical diags: weight, blood pressure, blood sugar
Additional "whole person" diagnostic trends: medication, diet, exercise,
stress, goals
Stored automatically into patient record
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Including triggering of alert messages (preventative, proactive)
Diagnostic ranges agreed upon by physician and patient
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Self-care
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Address chronic-illness crisis
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Compliance / Adherence --> Empowerment
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Mutually agreed upon SMART goals (patient & PCP)
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Tracking with alerts
Motivational outreach
Daily Plan with regular feedback
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Shared decision-making; patient-physician relationship
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Contextually appropriate educational content
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Access to relevant portions of medical record
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The Big Four Patient e-Requests
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Ask question where no visit is necessary (secure messaging)
Schedule an appointment
Refill a prescription
View lab results
Appropriate social networks / communities
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Workflow Optimization
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eScheduling (automated or parallelized requests)
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eRx (refill requests)
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Secure Messaging (online questions vs. office call/visit)
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Virtual Office Visit
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Electronic forms
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Automated pre-certifications
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eCommerce (online bill pay)
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Patient Reminders
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Appointments
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Medication compliance
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Diagnostic tests (ie annual foot exam)
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Goal progress (motivation)
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Population Registry
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Flag gaps in care
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Apply evidence-based guidelines for population (ie type-2
diabetics)
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Population trending
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Study correlation between interventions and outcomes
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Ad-hoc querying
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Case Study – Banner Health
Benefits of HIT
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84.3% - Avoidance of adverse drug events
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41.6% - Reduction in paper forms (95.6% reduction in document
storage costs)
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17.8% - Reduction in pharmacy costs
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15.8% - Decrease in nurse attrition
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5.3% - Reduction in overtime work
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2.2% - Reduction of days in accounts payable
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Case Study – Group Health Cooperative
Benefits of HIT
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58% - Eligible patients who enrolled (200,000+)
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33% - Patient encounters through secure messaging
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10% - Patients reviewing medical test results
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10% - Patients ordering prescription refills
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94% - Patients who were "satisfied" or "very satisfied" with
their access to online HIT
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50+% - Usage by patients with serious chronic condition
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Costs were recouped in the first year
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Making Technology Work
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Needs to be simple and intuitive to use by ALL relevant players
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Contextually & behaviorally relevant
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Scalable
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Incorporates "ecosystem of health"
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Empowers patients
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Built-in feedback mechanisms (incl. satisfaction surveys)
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Discussion Topics
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Can HIT actually reduce clinical quality?
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Work-flow disruption
Poor interface design (leading to lack of adoption)
Inappropriate (incorrect) use of decision-support tools
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Quality Predisposition Bias
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Contextual Dependency
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Academic vs. Non-Academic hospitals
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Data Standards and Integration
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Fragmentation
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Adoption times
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Reimbursement
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Costs & Skills Required (w/r/t Meaningful Use incentives)
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Patient Accessibility
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Patient Accessibility
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Patient Accessibility
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Summary
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Lots of challenges - especially w/r/t
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chronic illness costs & outcomes
patient & physician (+staff) satisfaction
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HIT can help improve quality & efficiency in many areas
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Effective integration and utilization of technology the most
difficult part
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Loading initial data (esp. if from paper records)
Internal and external processes (incl. integration w/ existing HIT)
Workflow management
Participation (by all relevant players)
Tuning for optimization
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PCPCC Paper on Meaningful Use - DRAFT
Even with well-established workflow processes and existing back-office systems already in place, jumping into the EHR
world is unfortunately not simply a matter of purchasing the necessary hardware/software, wiring it up, and turning it on.
It requires attention to several areas of practice organization and management.
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Develop a clear, shared understanding of why the practice is going down this HIT/EMR path (benefits, vision of future
state, etc.)
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Clearly understand the upfront costs (i.e. licensing, installation, hardware, etc.) as well as the on-going costs
(maintenance fees, software upgrades, training, hosting fees, etc.) for the HIT product(s) being installed
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Build a realistic understanding of the work involved in a successful EMR implementation – including elements such as:
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Length of the implementation
Temporary adjustments to normal office schedules due to staff involvement
Practice management redesign, including staff training, work-flow automation, etc.
Will EMR only be used by PCP (+staff) or:
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Will practice "executives" require access - if so, management reporting needed
Will patient have access (patient portal required)
Will other providers have access (ie specialists) - if so, need to incorporate their workflow/processes as well
Typical sources of physician and staff concern, and proven ways to address
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Develop a clear process for issue escalation, both internal to the practice and external with the HIT vendor(s). Ideally,
fold into the vendor contracts up front exactly how issues will be handled.
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Identify clearly defined, short-term, attainable milestones and track progress against them
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Consider contingency plans up front such that worst-case scenarios are “pre-planned” and ideally “pre-mitigated”
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Communicate regularly with all staff on progress. Celebrate successes and develop “lessons learned” from any
setbacks.
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Consider after-visit discussions with patients to both engage them in the practices’ implementation of their electronic
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medical record and to solicit patient feedback.
Thank You.
www.healthyhumans.com
Anthony Gold
Healthy Humans, CEO
[email protected]
(484) 857-2323
Blog: anthonygold.info