1 Health Information Technology Citizen’s Health Care Working Group Presented by Scott D. Williams, M.D., M.P.H. Vice-President, HealthInsight July 22,

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Health Information Health Information TechnologyTechnology

Citizen’s Health Care Working GroupCitizen’s Health Care Working Group

Presented byPresented by

Scott D. Williams, M.D., M.P.H.Scott D. Williams, M.D., M.P.H.

Vice-President, HealthInsightVice-President, HealthInsight

July 22, 2005July 22, 2005

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OverviewOverview• HealthInsightHealthInsight

Medicare Quality Improvement Organization (QIO) with Medicare Quality Improvement Organization (QIO) with CMS contract for Utah and NevadaCMS contract for Utah and Nevada

DOQ-IT Project PilotDOQ-IT Project Pilot• Promoting the use of Electronic Medical Records in small and Promoting the use of Electronic Medical Records in small and

medium primary care physician officesmedium primary care physician offices

• Utah Health Information Network (UHIN)Utah Health Information Network (UHIN) 12 years of successful administrative health data exchange 12 years of successful administrative health data exchange

• Claims, remittance, eligibilityClaims, remittance, eligibility• Credentialing, coordination of benefits, EFT Credentialing, coordination of benefits, EFT

Regional Health Information Organization development Regional Health Information Organization development grantee (AHRQ)grantee (AHRQ)

• Labs, pharmacy, clinical notes and reportsLabs, pharmacy, clinical notes and reports

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Issues in Health ITIssues in Health IT• TechnologyTechnology

• ArchitectureArchitecture• Hardware/ SoftwareHardware/ Software• ConnectionsConnections• SupportSupport

• GovernanceGovernance• Community Community

interestsinterests• Privacy, securityPrivacy, security• Resource allocationResource allocation

• ValueValue• Who benefits & Who benefits &

who pays?who pays?• EfficiencyEfficiency• OutcomesOutcomes

• StandardsStandards• Self-regulatedSelf-regulated• Externally- Externally-

regulatedregulated• Market drivenMarket driven

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Health IT: ApplicationsHealth IT: Applications

• Electronic Medical Record (EMR)Electronic Medical Record (EMR)Paperless officePaperless officePersonal Health RecordPersonal Health Record

• Health Information Exchange (HIE)Health Information Exchange (HIE)Regional Health Information Org. (RHIO)Regional Health Information Org. (RHIO)Allows interoperability between stakeholdersAllows interoperability between stakeholders

• Clinical Decision Support Systems (CDSS)Clinical Decision Support Systems (CDSS)Case and cohort managementCase and cohort managementComputerized Physician Order Entry (CPOE)Computerized Physician Order Entry (CPOE)Prompts, recalls, trends, protocols, drug Prompts, recalls, trends, protocols, drug

interactions, generics, performance measures interactions, generics, performance measures

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Value: Administrative Health DataValue: Administrative Health Data• UHIN (17 million claims/year)UHIN (17 million claims/year)

Efficiency of Claims Processing by 1 adjudicatorEfficiency of Claims Processing by 1 adjudicator• Paper Paper 100-150/ day100-150/ day• Scanned Scanned 300/ day300/ day• EDI EDI 700-800/ day700-800/ day• AutoprocessingAutoprocessing 60% of claims require no 60% of claims require no

human involvement human involvementPayer value- just for intake of claimPayer value- just for intake of claim

• Paper = $6-10/ claimPaper = $6-10/ claim• EDI < $1/ claimEDI < $1/ claim

Provider valueProvider value• Faster paymentsFaster payments• Fewer rejected claimsFewer rejected claims• Less staff timeLess staff time

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Lessons Learned: UHIN Lessons Learned: UHIN

• Champion- credible, neutral, trustedChampion- credible, neutral, trusted• Value accrues to all participantsValue accrues to all participants

Drives prioritiesDrives prioritiesDrives business modelDrives business model

• Community ownership & governanceCommunity ownership & governanceConsensus decision makingConsensus decision making

• Standards drivenStandards driven• Use of data subject to governance Use of data subject to governance

processprocess

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Value: EMRsValue: EMRs

HIMSS, September 2004

EMR Adoption

Physician Offices 17%

Hospital ER 31%

Hospital Outpatient 29%

CDC March 2005

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Value: EMR Adoption Barriers Value: EMR Adoption Barriers among Physiciansamong Physicians

• Initial Capital Cost Initial Capital Cost (345/423, ms = 1.85)(345/423, ms = 1.85)

• Time Cost Time Cost (323/423, ms = 2.74)(323/423, ms = 2.74)

• Confidentiality and Confidentiality and Security Concerns Security Concerns (181/423, ms = 2.93)(181/423, ms = 2.93)

• Maintenance cost Maintenance cost (300/423, ms = 3.00)(300/423, ms = 3.00)

• Interfere with doctor-Interfere with doctor-patient communicationpatient communication

• Concerns about Concerns about learning new learning new technologytechnology

• Lack of technical Lack of technical supportsupport

• Lack of control over Lack of control over decisiondecision

• Lack of perceived Lack of perceived benefitsbenefits

ms = mean score

Massachusetts Medical Society Survey Spring 2003

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Value: EMR Business Case for the Value: EMR Business Case for the PhysicianPhysician

• Process efficiency (requires workflow redesign)Process efficiency (requires workflow redesign) TranscriptionTranscription FormsForms Telephone callsTelephone calls Information collection from patientsInformation collection from patients

• Lower overheadLower overhead Fewer FTEsFewer FTEs Less space needed for chartsLess space needed for charts

• Increased reimbursementIncreased reimbursement Better coding & recoveryBetter coding & recovery More patients seen (if workflow changes)More patients seen (if workflow changes) Pay for PerformancePay for Performance

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Mean BenefitMean Benefit Low EndLow End High EndHigh End

Savings (paperless, Savings (paperless, capitated = 17%, capitated = 17%,

Fee for service = 83%)Fee for service = 83%)

$50,300$50,300 $21,800$21,800 $85,600$85,600

Costs, Year 1 (hardware, Costs, Year 1 (hardware, software, inefficiency, software, inefficiency, licenses, support, licenses, support, updates)updates)

$22,100$22,100 $13,700$13,700 $36,000$36,000

Costs, Year 2 +Costs, Year 2 + $5,300$5,300 $2,600$2,600 $9,500$9,500

Total ROI, Year 1Total ROI, Year 1 $28,200$28,200 $8,000$8,000 $49,600$49,600

Total ROI, Year 2+Total ROI, Year 2+ $45,000$45,000 $19,000$19,000 $76,100$76,100

Wang, S.J. et al. 2003

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Wenner Georgia HIMSS Dec 2002

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Wenner Georgia HIMSS Dec 2002

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Value: HIEValue: HIE

• Automation of clinical processesAutomation of clinical processes

• More timely, complete, accurate More timely, complete, accurate patient information at point of patient information at point of serviceservice

• Efficiency of connectivityEfficiency of connectivity

• Facilitate clinical decision support Facilitate clinical decision support systems across communitiessystems across communities

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Value: HIEValue: HIE• Missing Patient DataMissing Patient Data

13.6% of primary care physician visits13.6% of primary care physician visits52% of missing data resides outside of system52% of missing data resides outside of system44% of data somewhat likely to adversely affect 44% of data somewhat likely to adversely affect

patientspatients60% of data likely to delay care or result in 60% of data likely to delay care or result in

additional servicesadditional servicesMore likely among recent immigrants, new patients, More likely among recent immigrants, new patients,

those with complex medical problemsthose with complex medical problemsLess likely where physician has full EMR and also Less likely where physician has full EMR and also

in rural areasin rural areas

Smith et al. JAMA. February 2005

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Hospitals

Primary care physician

Specialty physician

Ambulatory center (e.g.

imaging centers)

Payors

Pharmacy

Laboratory

Public health

Current system fragments patient information and creates redundant, inefficient efforts

Pharmacy

Laboratory

Hospitals

Primary care physician

Specialty physician

Ambulatory center (e.g.

imaging centers)

Payors

Public health

HealthInformationExchange

Future system will consolidate information and provide a foundation for unifying efforts

Source: Indiana Health Information Exchange

RHIOs: “Wiring” Healthcare RHIOs: “Wiring” Healthcare EfficientlyEfficiently

RHIOs: “Wiring” Healthcare RHIOs: “Wiring” Healthcare EfficientlyEfficiently

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Value: HIEValue: HIE• Based on published data and expert opinionBased on published data and expert opinion• Interoperability Interoperability

Level 2 = FaxLevel 2 = Fax Level 3 = Machine-organizable dataLevel 3 = Machine-organizable data Level 4 = Machine-interpretable dataLevel 4 = Machine-interpretable data

• Net Value after full implementationNet Value after full implementation Level 2 = $21.6 billion /yearLevel 2 = $21.6 billion /year Level 3 = $23.9 billion/ yearLevel 3 = $23.9 billion/ year Level 4 = $77.8 billion/ yearLevel 4 = $77.8 billion/ year

• Costs: Benefit Calculation for Costs: Benefit Calculation for Level 4Level 4 Years 1-10 = $276 billion: $613 billion = $338 billionYears 1-10 = $276 billion: $613 billion = $338 billion Year 11 + = $16.5 billion: $94.3 billion = $77.8 billionYear 11 + = $16.5 billion: $94.3 billion = $77.8 billion

Walker et al. Health Affairs. January 2005

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Value: Level 4 HIEValue: Level 4 HIE• Contributions to the $94.3 billion benefit: Service categoriesContributions to the $94.3 billion benefit: Service categories

• Contributions to the $16.5 billion costContributions to the $16.5 billion cost

Laboratory testingLaboratory testing $31.8 billion$31.8 billion

ImagingImaging $26.2 billion$26.2 billion

Provider-payer transactionsProvider-payer transactions $20.1 billion$20.1 billion

Chart transfers between providersChart transfers between providers $13.2 billion$13.2 billion

PharmacyPharmacy $2.71 billion$2.71 billion

Public health reportingPublic health reporting $195 million$195 million

Clinical office system costClinical office system cost $9.08 billion$9.08 billion

Hospital system costHospital system cost $1.58 billion$1.58 billion

Provider interface costProvider interface cost $5.40 billion$5.40 billion

Stakeholder interface costStakeholder interface cost $467 million$467 million


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Value: Level 4 HIEValue: Level 4 HIE

ProvidersProviders $33.7 billion$33.7 billion

PayersPayers $27.6 billion$27.6 billion

LaboratoriesLaboratories $13.1 billion$13.1 billion

Radiology centersRadiology centers $8.2 billion$8.2 billion

PharmaciesPharmacies $1.3 billion$1.3 billion

Public health departmentsPublic health departments $94 million$94 million

•Where does $77.8 billion net value accrue (HIE Only)?Where does $77.8 billion net value accrue (HIE Only)?


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Value: Level 4 HIEValue: Level 4 HIE

• 50-200 Bed Hospital50-200 Bed Hospital$2.7 million in IT investment$2.7 million in IT investment$250,000/year in maintenance$250,000/year in maintenance$1.3 million/year in transaction savings$1.3 million/year in transaction savings

• $570,000 from other providers$570,000 from other providers• $200,000 from other laboratories$200,000 from other laboratories• $170,000 from radiology centers$170,000 from radiology centers• $250,000 from payers$250,000 from payers• $70,000 from pharmacies$70,000 from pharmacies


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HIE: UHIN ApproachHIE: UHIN Approach

• Identify value-based priority use Identify value-based priority use cases with interested stakeholderscases with interested stakeholders

• Obtain broader stakeholder supportObtain broader stakeholder support• Develop and adopt technical modelDevelop and adopt technical model• Develop and adopt financing modelDevelop and adopt financing model• Convene standards development Convene standards development

processprocess• Adopt standardsAdopt standards• Pilot, refine, implementPilot, refine, implement

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“...risk-adjusted cost varied almost 3-fold...”

Duke Clinical Research Institute 2002

70%

30%

Project Hope, Wennberg et.al., 2003/HealthAlliant

“...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

“...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.

“...30% of direct health care outlays are the result of poor-quality care...”

MBGH, Juran, et al 2002

Practice Variation

Value: CDSSValue: CDSS

Annual U.S. health care expenditures: $1.7 trillion x 30% = ~ $500 billion

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Value: CDSSValue: CDSSCPOECPOE

• 25% improvement in ordering of 25% improvement in ordering of corollary medications by faculty corollary medications by faculty and residents (p<0.0001) Overhage, and residents (p<0.0001) Overhage, 19971997

• 55% decrease in non-intercepted 55% decrease in non-intercepted serious medication errors (p=0.01) serious medication errors (p=0.01) Bates, 1999Bates, 1999

• 81% decrease in medication errors 81% decrease in medication errors

(p<0.0001) Bates, 1999 (p<0.0001) Bates, 1999

• Improvement in 5 prescribing Improvement in 5 prescribing practices (p<0.001) Teich, 2000practices (p<0.001) Teich, 2000

CDSSCDSS

• 6 of 14 studies showed 6 of 14 studies showed improvement in patient improvement in patient outcomes. Hunt 1998outcomes. Hunt 1998

• 43 of 65 studies showed 43 of 65 studies showed improvement in physician improvement in physician performance. Hunt 1998performance. Hunt 1998

• 17% improvement in antibiotic 17% improvement in antibiotic regimen suggested by computer regimen suggested by computer consultant versus physicians consultant versus physicians (p<0.001) Evans 1994(p<0.001) Evans 1994

• 70% decrease in adverse drug 70% decrease in adverse drug events caused by anti-infectives events caused by anti-infectives (p=0.02) Evans 1998(p=0.02) Evans 1998

Source: Center for Information Technology Leadership, 2003

23Source: SBCCDE, CITL, Gordian Project analysis

Redundancy

Treatment

Errors

Diagnostic

EMR HIE CDSS

Patient Data

Medical Knowledge

50% of Cost20% of Return

100%

Value: CDSSValue: CDSS

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Value: Outpatient CPOEValue: Outpatient CPOE

• Savings from nationwide adoptionSavings from nationwide adoptionAdverse Drug Reactions = $2 billionAdverse Drug Reactions = $2 billion

• Eliminate 2 million adverse drug reactionsEliminate 2 million adverse drug reactions• Eliminate 190,000 hospitalizationsEliminate 190,000 hospitalizations

Medication management = $27 billionMedication management = $27 billionRadiology management = $10.4 billionRadiology management = $10.4 billionLaboratory management = $4.7 billionLaboratory management = $4.7 billion

Total = $44 billionTotal = $44 billionSource: Center for Information Technology Leadership, 2003

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Value: Who benefits? Value: Who benefits? Who Pays?Who Pays?

% of Savings Captured by

11%89% Physicians

Source: Center for Information Technology Leadership, 2003

Ambulatory Computer-based Physician Order Entry

Private Payers

Medicare

Medicaid

Self-insured

Self-pay

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Health IT: Federal Government RolesHealth IT: Federal Government Roles

• Facilitate the implementation of a national Facilitate the implementation of a national strategystrategy

• Support innovation experimentsSupport innovation experiments• Confirm business value and align incentivesConfirm business value and align incentives• Coordinate the implementation strategies of Coordinate the implementation strategies of

federal health care agenciesfederal health care agencies• Assure the rapid development of data and Assure the rapid development of data and

technical standards with broad inputtechnical standards with broad input• Assure that privacy and security regulations Assure that privacy and security regulations

don’t encumber interstate health data exchangedon’t encumber interstate health data exchange• Incentivize health IT savings to be redirected into Incentivize health IT savings to be redirected into

effective health care interventionseffective health care interventions

Documents

1 Health Information Technology Citizen’s Health Care Working Group Presented by Scott D. Williams, M.D., M.P.H. Vice-President, HealthInsight July 22,