California Council on Science and Technology Steve Ryan February 3, 2005 California Council on Science and Technology Steve Ryan February 3, 2005

California Council on Science and Technology

Steve RyanFebruary 3, 2005

Healthcare Issuesin the U.S. and CaliforniaHealthcare Issuesin the U.S. and California

• Health insurance coverage for all• Quality and safety of health care• Cost and affordability of health care• Information technology in health (HIT)

• Electronic Health Record (eHR or EMR)• Comparative performance

• Outcome measures

• Health insurance coverage for all• Quality and safety of health care• Cost and affordability of health care• Information technology in health (HIT)

• Electronic Health Record (eHR or EMR)• Comparative performance

• Outcome measures

Healthcare Issues(continued)Healthcare Issues(continued)

• Health workforce shortages, low professional morale, and mismatches of personnel to care needs – including nursing staffing and training

• Underinvestment in disease prevention, health protection, and public health infrastructure

• Health illiteracy• Coherent strategies, incentives, and systems to

promote scientific discovery• Pressures on Academic Health Centers• Inadequate management of chronic diseases

• Health workforce shortages, low professional morale, and mismatches of personnel to care needs – including nursing staffing and training

• Underinvestment in disease prevention, health protection, and public health infrastructure

• Health illiteracy• Coherent strategies, incentives, and systems to

promote scientific discovery• Pressures on Academic Health Centers• Inadequate management of chronic diseases

Healthcare Issues(continued)Healthcare Issues(continued)

• Disparities in care and outcomes• Closure of trauma-emergency rooms• Payor Issues

• No more managed care• All insurance

• Employers – have decided to exit• Defined contribution- not benefit• Outsourcing

• STEM CELLS• Seismic Code – Hospital Compliance

• Disparities in care and outcomes• Closure of trauma-emergency rooms• Payor Issues

• No more managed care• All insurance

• Employers – have decided to exit• Defined contribution- not benefit• Outsourcing

• STEM CELLS• Seismic Code – Hospital Compliance

Healthcare 15% GDP

• Hospitals OPD 9-14% • Prescription Drugs 9%• MDs 5%

Healthcare 15% GDP

• Hospitals OPD 9-14% • Prescription Drugs 9%• MDs 5%

Consumer Survey by HarrisConsumer Survey by Harris

• 59% HIT will give them control in managing their health

• 63% HIT will prevent unnecessary visits• 52% believe they will benefit from cost savingsBUT• 53% believe HIT will be more trouble than

current system• 77% concerned MDs will miss clues apparent

in ‘face to face’• 61% believe HIT will increase cost of HC• 89% believe they will pay for increased costs

• 59% HIT will give them control in managing their health

• 63% HIT will prevent unnecessary visits• 52% believe they will benefit from cost savingsBUT• 53% believe HIT will be more trouble than

current system• 77% concerned MDs will miss clues apparent

in ‘face to face’• 61% believe HIT will increase cost of HC• 89% believe they will pay for increased costs

SummarySummary

• HIT is HOT AREA in Health Care• President Bush – David Brailer• California leaders

• Goals• Improve quality and safety• Reduce cost and improve efficiency

• HIT is HOT AREA in Health Care• President Bush – David Brailer• California leaders

• Goals• Improve quality and safety• Reduce cost and improve efficiency

HIT in Health CareHIT in Health Care

• Reduction of medical errors• MDs ready access to

• Best practice guidelines• Evidence databases

• EMR in HC network• Reduce costs• Eliminate redundancy• Speed delivery of care

• Reduction of medical errors• MDs ready access to

• Best practice guidelines• Evidence databases

• EMR in HC network• Reduce costs• Eliminate redundancy• Speed delivery of care

HIT CaseHIT Case

• More theoretical than proven• E.g. <10% of hospitals use CPOE

• Broad scale interventions and policy changes to transform practice of medicine• Government policy makers• Health system executives

• More theoretical than proven• E.g. <10% of hospitals use CPOE

• Broad scale interventions and policy changes to transform practice of medicine• Government policy makers• Health system executives

RAND ProjectRAND Project

• Quantitative model• Estimate costs and benefits

• Elimination of medical errors Acute Care Mortality Costs for HC payers and

organizations

• Quantitative model• Estimate costs and benefits

• Elimination of medical errors Acute Care Mortality Costs for HC payers and

organizations

From: Brook and HillestadFrom: Brook and Hillestad

RAND Project (continued)RAND Project (continued)

• Quantify HC quality and savings from HIT

• Process view in a system model• Focus on benefits, costs, barriers,

and enablers of FUTURE HIT

• Quantify HC quality and savings from HIT

• Process view in a system model• Focus on benefits, costs, barriers,

and enablers of FUTURE HIT

HIT and PhysiciansHIT and Physicians

• 90+ % - Personal use of internet• <20% (?5%) EMR

• 90+ % - Personal use of internet• <20% (?5%) EMR

HIT and PhysiciansHIT and Physicians

Barriers to Adoption of HIT• Start up costs – 56%• Lack of uniform standards – 44%• Lack of time – 39%

Need HIT tools for all MDs• Accessible• Affordable

Barriers to Adoption of HIT• Start up costs – 56%• Lack of uniform standards – 44%• Lack of time – 39%

Need HIT tools for all MDs• Accessible• Affordable

Barriers to EMR ImplementationBarriers to EMR Implementation

• Organizational• Data• Cultural• Capital

• $50,000+ per MD• 48+ hours training

Wal Mart – organized around coherent goal

HC – Complexity, fluid, patient clues to MD

• Organizational• Data• Cultural• Capital

• $50,000+ per MD• 48+ hours training

Wal Mart – organized around coherent goal

HC – Complexity, fluid, patient clues to MD

Patient ConfidentialityPatient Confidentiality

• Early concerns, e.g.• Local newspaper access to medical histories

• HIPAA• Human Interaction

• Patient and Physician (HC Provider)

• Early concerns, e.g.• Local newspaper access to medical histories

• HIPAA• Human Interaction

• Patient and Physician (HC Provider)

Consumers favor IT in areas of HC but in some areas frequently prefer and demand “high touch” approaches

Consumers favor IT in areas of HC but in some areas frequently prefer and demand “high touch” approaches

The Actual Drivers of Transformation TodayThe Actual Drivers of Transformation Today

• The transformation of healthcare in California has been driven by:• Health Plans• Medical groups, IPAs• Employers• State government• Hospitals

• The impact of information technology is at early stage• Demonstrations by medical groups, IPAs• Larger investments underway by delivery

systems, health plans

ModelsModels

Mayo – IBM

Enabling LegislationDelawareFloridaWyoming

Mayo – IBM

Enabling LegislationDelawareFloridaWyoming

California StatusCalifornia Status

• Trails Other States• Pockets of EMR Implementation

• Kaiser

• Trails Other States• Pockets of EMR Implementation

• Kaiser

California Has National Leaders in Healthcare ITCalifornia Has National Leaders in Healthcare IT

• Robert Brook and Richard Hillestad – RAND• Molly Coye – HealthTech• Jack Lewin – CMA• Leonard Schaeffer – WellPoint (Anthim)• Many others• Other National Leaders

• David Brailer• Harvey Fineberg• Don Berwick• Don Detmer

• Robert Brook and Richard Hillestad – RAND• Molly Coye – HealthTech• Jack Lewin – CMA• Leonard Schaeffer – WellPoint (Anthim)• Many others• Other National Leaders

• David Brailer• Harvey Fineberg• Don Berwick• Don Detmer

GOALGOAL

Application of Information Technology to Healthcare

• Improve Quality of Healthcare• Protect Patients from Medical Error

• Reduce Cost of Healthcare• Avoid unnecessary duplication• Integrate Healthcare System

• Payors• Providers• Public

Application of Information Technology to Healthcare

• Improve Quality of Healthcare• Protect Patients from Medical Error

• Reduce Cost of Healthcare• Avoid unnecessary duplication• Integrate Healthcare System

• Payors• Providers• Public

Health Information NetworkHealth Information Network

• High quality care• Safer care• Lower cost

• Reduce • Duplicate Diagnostic Tests• Unnecessary Admissions

• High quality care• Safer care• Lower cost

• Reduce • Duplicate Diagnostic Tests• Unnecessary Admissions

Patient Safety InstitutePatient Safety Institute

• Create integrated statewide• Clinical Information• Sharing Networks

• Jack Lewin, M.D. – CMA EVP/CEO

• Create integrated statewide• Clinical Information• Sharing Networks

• Jack Lewin, M.D. – CMA EVP/CEO

System BenefitsSystem Benefits

• Patient-specific individual medicine• Disease surveillance• Research• Pay for units

• Pay for performance (outcomes)

• Patient-specific individual medicine• Disease surveillance• Research• Pay for units

• Pay for performance (outcomes)

From: Lewin/PSIFrom: Lewin/PSI

FDA/Pharmaceutical BenefitsFDA/Pharmaceutical Benefits

• FDA surveillance of past approval (Phase 4)

• Pharmaceutical Industry• Costs and profits• Safety

• FDA surveillance of past approval (Phase 4)

• Pharmaceutical Industry• Costs and profits• Safety


Technology Exists ForTechnology Exists For

• First systemic approach to monitoring and surveillance of adverse drug effects

• MDs to monitor compliance with Rx regimen

• Lowering overall cost of health care• Faster patient recruitment for clinical

trials

• First systemic approach to monitoring and surveillance of adverse drug effects

• MDs to monitor compliance with Rx regimen

• Lowering overall cost of health care• Faster patient recruitment for clinical

trials


Barriers to Statewide NetworksBarriers to Statewide Networks

• No demonstrated scalable architecture supported by MDs – Hospitals – Consumers

• No national trusted third party• No viable business model

• No demonstrated scalable architecture supported by MDs – Hospitals – Consumers

• No national trusted third party• No viable business model


Architecture: Selected FeatureArchitecture: Selected Feature

• Giant Master Patient Index or Switch links and retrieves disparate medical information at originating sources

• Reliable and Fast. 99.98% availability; patient-centric record in 4 to 5 seconds

• Non-profit PSI and its members own the license for the open architecture technology, not a for profit vendor

• Giant Master Patient Index or Switch links and retrieves disparate medical information at originating sources

• Reliable and Fast. 99.98% availability; patient-centric record in 4 to 5 seconds

• Non-profit PSI and its members own the license for the open architecture technology, not a for profit vendor


Molly Coye, M.D.Molly Coye, M.D.

Health Tech - Founder & CEO

A.H.A - Board

IOM• To Err is Human• Crossing the Quality Chasm

California - Director of DHS

New Jersey - Commissioner

Health Tech - Founder & CEO

A.H.A - Board

IOM• To Err is Human• Crossing the Quality Chasm

California - Director of DHS

New Jersey - Commissioner

From: Coye/HealthTechFrom: Coye/HealthTech

Molly Coye – Health Tech ConvenedMolly Coye – Health Tech Convened

StakeholdersPayors - InsuranceProviders - MDs

- Hospitals- Pharmaceuticals

Government

Technology - CISCO- Oracle- HP

StakeholdersPayors - InsuranceProviders - MDs

- Hospitals- Pharmaceuticals

Government

Technology - CISCO- Oracle- HP


The Need for State LeadershipThe Need for State Leadership

California lags• Legislation: Wyoming, Florida, Delaware

• Planning bodies • Funding• Stakeholders brought to the table

• Medicaid and indigent care:• Disease management• Investment in IT as administrative match

• RHIO formation:• > 400 communities in the U.S.

California lags• Legislation: Wyoming, Florida, Delaware

• Planning bodies • Funding• Stakeholders brought to the table

• Medicaid and indigent care:• Disease management• Investment in IT as administrative match

• RHIO formation:• > 400 communities in the U.S.


California Health Information Exchange Project - VisionCalifornia Health Information Exchange Project - Vision

• VISION• Support the use of information

technology, and the creation of a statewide health information data exchange system to:

• Improve the safety and quality of healthcare in California

• Improve the efficiency of healthcare in California

• VISION• Support the use of information

technology, and the creation of a statewide health information data exchange system to:

• Improve the safety and quality of healthcare in California

• Improve the efficiency of healthcare in California


Better, Cheaper Care – and Projections of State SavingsBetter, Cheaper Care – and Projections of State Savings

• Projected net annual benefit, at 75% adoption rate, for Massachusetts: $2.48 billion• Electronic communication between patients and

their physicians• Electronic prescribing• Ambulatory computerized physician order entry• Inpatient CPOE• Regional data sharing• Intensivist onsite 24x7 in ICUs• Disease management

New England Healthcare Institute: Advancing Innovation, November 2003 www.nehi.net

• Projected net annual benefit, at 75% adoption rate, for Massachusetts: $2.48 billion• Electronic communication between patients and

their physicians• Electronic prescribing• Ambulatory computerized physician order entry• Inpatient CPOE• Regional data sharing• Intensivist onsite 24x7 in ICUs• Disease management

New England Healthcare Institute: Advancing Innovation, November 2003 www.nehi.net

New England Healthcare Institute Estimates – Massachusetts SavingsNew England Healthcare Institute Estimates – Massachusetts Savings

0

500

1,000

1,500

2,000

2,500

3,000

$977

$710

$290

$177$168

$140

Inpatient CPOE

Disease Management

AmbulatoryCPOE

E-ICU

Patient-Physician

Email

E-Prescribing

Regional Data Sharing

Total Net Annual Benefit: $2.5 Billion

$ M

illio

ns

Advanced Technologieswww.nehi.net - October 2003

$24

Year2003

Diff

usio

n of

Tec

hnol

ogy

Everett Rogers, Diffusion of Innovations, 1995

The Tipping Point – Are We There Yet?The Tipping Point – Are We There Yet?

Early Adopters (13.5%)

Early Majority (34%)

Late Majority (34%)

Innovators (2.5%)

Laggards (16%)

Tipping Point

Tipping Point

Emergence of Health Data Exchange in CaliforniaEmergence of Health Data Exchange in California

FAILEDFAILEDEXPERIMENTSEXPERIMENTS

CDHSv SYS

MedUnite

Calinx

Others

Plans

Medical Groups

IPAs

IDNs

Medi-Cal

Regional Data-SharingOrganizations

QIO

CURRENTCURRENTEFFORTSEFFORTS

Leadership

Clinical Data Standards,EHR Definition

Seed + Demo Funding

Purchaser: FEHBP

Interoperability Commission

Product CertificationCommission

Reimbursement

RHIO Definition

Stark, Fraud & AbuseModification

FEDERALFEDERALINITIATIVESINITIATIVES

Principles

Benefits + Costs Framework

Financing Models,Funding

Platform Technologies

Enabling Legislation,Regulation

Governance

RHIO(s) Formed

CALIFORNIACALIFORNIANETWORKNETWORK


California Health Information Exchange Project - GoalsCalifornia Health Information Exchange Project - Goals

Cal-RHIO GOALS• to help the organizers of regional efforts in California share

information, materials, technology, and learnings• to facilitate

• development of common governance, processes, technology, and other elements of regional healthcare information organizations (‘RHIOs’) in California, and

• encourage the formation of one or more RHIOs within the state, with a statewide umbrella organization

• to help key stakeholders in the health care and business communities and state policy leaders develop private and public policy agendas that will support the

• rapid development and implementation of health care information technology within California, and the

• protected exchange of that information

Cal-RHIO GOALS• to help the organizers of regional efforts in California share

information, materials, technology, and learnings• to facilitate

• development of common governance, processes, technology, and other elements of regional healthcare information organizations (‘RHIOs’) in California, and

• encourage the formation of one or more RHIOs within the state, with a statewide umbrella organization

• to help key stakeholders in the health care and business communities and state policy leaders develop private and public policy agendas that will support the

• rapid development and implementation of health care information technology within California, and the

• protected exchange of that informationFrom: Coye/HealthTechFrom: Coye/HealthTech

California Health Information Exchange Project - CommitmentsCalifornia Health Information Exchange Project - Commitments

COMMITMENTS• to promote widespread access to the

benefits of information technology and data exchange for underserved populations and safety net providers

• to make the project, its website and publications, and proposals for organizational or technical developments publicly available for comment and contributions.

COMMITMENTS• to promote widespread access to the

benefits of information technology and data exchange for underserved populations and safety net providers

• to make the project, its website and publications, and proposals for organizational or technical developments publicly available for comment and contributions.


California Health Information Exchange Project – Draft PrinciplesCalifornia Health Information Exchange Project – Draft Principles

DRAFT PRINCIPLES• Transparent• Common approaches to technology,

governance, financing, and other aspects of information technology investment and data exchange• Across California• Between California and national efforts

• Sound business and financing models for each component

• Inclusive

DRAFT PRINCIPLES• Transparent• Common approaches to technology,

governance, financing, and other aspects of information technology investment and data exchange• Across California• Between California and national efforts

• Sound business and financing models for each component

• Inclusive


Communication &Communication &Summit PlanningSummit PlanningWorking GroupWorking Group

Coordination of Coordination of Local EffortsLocal Efforts

FinanceFinanceWorking GroupWorking GroupClinicalClinical

Working GroupWorking Group

TechnicalTechnicalWorking GroupWorking Group

GovernanceGovernanceWorking GroupWorking Group

$FundingFundingCouncilCouncil

Projects

BB CC

AA

California Health Information Exchange Project - OrganizationCalifornia Health Information Exchange Project - Organization

STATEWIDE UMBRELLA ORGANIZATION

Project OfficeProject OfficeHealthTechHealthTech

Steering GroupSteering Group


www.healthtech.orgwww.healthtech.org

The VisionAdvancing the use of new technology to make people healthier

The MissionTo create a trusted source of expert information about the future of health care technologies

The MeansA non-profit pooled research center for delivery systems and health plans.Funding independent of developers and vendors of technology

The VisionAdvancing the use of new technology to make people healthier

The MissionTo create a trusted source of expert information about the future of health care technologies

The MeansA non-profit pooled research center for delivery systems and health plans.Funding independent of developers and vendors of technology


State Agenda for IT TransformationState Agenda for IT Transformation

Federal role:• Clear the underbrush

• Standards and certification• Fraud and abuse, Stark• Enable RHIOs

• Build the highways• Network certification for data exchange• Public use data:

• Public health• Quality and safety• Defense

• Health quality and efficiency reports

• Reimbursement

Federal role:• Clear the underbrush

• Standards and certification• Fraud and abuse, Stark• Enable RHIOs

• Build the highways• Network certification for data exchange• Public use data:

• Public health• Quality and safety• Defense

• Health quality and efficiency reports

• ReimbursementFrom: Coye/HealthTechFrom: Coye/HealthTech

State Agenda for IT TransformationState Agenda for IT Transformation

State agenda:• ‘Bank accounts’ for all

• EHR, direct access for all Californians• Security and confidentiality• Access for underserved

• Neural networks across the state• Providers, anceillary, plans, patients• Regional data exchange networks coalesce • Establish RHIOs to provide governance, financing

• State investment in IT and IT-enabled programs• Medi-Cal financing and savings• Uninsured, county responsibilities• Private public infrastructure model• Remote management approaches• Rapid research and deployment mechanisms

• Focus on chronic care, disabled, rural and underserved, and SNF populations

• Reduce risk • Generate savings

• Need for leadershipFrom: Coye/HealthTechFrom: Coye/HealthTech

GOALGOAL

Information technology and creation of statewide health information data exchange to:

• Improve quality and safety of healthcare in California

• Improve efficiency and provide cost effective healthcare in California

Information technology and creation of statewide health information data exchange to:

• Improve quality and safety of healthcare in California

• Improve efficiency and provide cost effective healthcare in California

Documents

California Council on Science and Technology Steve Ryan February 3, 2005 California Council on Science and Technology Steve Ryan February 3, 2005