Role%20of%20the%20EHR%20in%20Healthcare%20Reform%20of%20Integrated%20Health%20Care%20Systems

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Role of the EHR in Healthcare Reform of
Integrated Health Care Systems

• Blackford Middleton, MD, MPH, MSc
• Partners HealthCare System,
• Harvard Medical School

2
Agenda

• Principal components of healthcare reform
• Partners High Performance Medicine
• Current Research Development
• Smart use of EMR Clinical Decision Support
• Quality Dashboards
• Patient Activation
• Clinical Decision Support Consortium

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Principal Components of Healthcare Reform

• President Obamas FY 2010 Budget overview
• Reduce long-term growth of health care costs for
  businesses and government.
• Protect families from bankruptcy or debt because
  of health care costs.
• Guarantee choice of doctors and health plans.
• Invest in prevention and wellness.
• Improve patient safety and quality care.
• Assure affordable, quality health coverage for
  all Americans.
• Maintain coverage when you change or lose your
  job.
• End barriers to coverage for people with
  pre-existing medical conditions.

• The New Healthcare Policy ABCDE
• Access
• Best Quality
• Cost
• Disparities
• (Comparative) Effectiveness

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Partners HealthCare System

• Eleven hospitals, 7000 physicians
• 6.4B in revenues
• 4M outpatient visits and 160,000 admissions/year
• 1B in biomedical research annually
• Teaching affiliate of the Harvard Medical School
• Founded by the Brigham and Womens Hospital and
  the Massachusetts General Hospital

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Information Systems Descriptive Numbers

• Operating budget (FY07) 158M
• Capital budget (FY08) 45M
• Number of users 54,000
• Devices on the network 71,000
• Locations on the Partners network 140
• Electronic Medical Record physician users 4,000
  (gt 100 of AMC PCPs 75 of Specialists)

• Patients with data in the clinical data
  repository 4,000,000
• Medical images on line 450,000,000
• Orders entered hourly through Computerized
  Provider Order Entry (across Partners) 1,000
• LMR (ambulatory EMR) transactions per day 1M
• Calls to the Help Desk each month 18,000

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Major Information Systems Initiatives

• Provision of electronic medical records,
  computerized provider order entry, electronic
  medication administration records and clinical
  decision support to further the goals of High
  Performance Medicine
• Implementation of COMPASS to standardize and
  improve revenue cycle processes across Partners
• Creation of the next generation of healthcare
  information systems architecture through the
  Service Oriented Architecture (SOA) initiative

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What is High Performance Medicine?
HPM comprises five System-wide projects with one
common goal

• To deliver better care to patients.
• Care that is
• Safer
• Better coordinated
• More reliable in delivering proven interventions
• Systems that support providers in doing the
  right thing.

Dr. Jim Mongan
http//www.partners.org/about/hpm.htm
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What are the High Performance Medicine
Initiatives?

• Investing in quality and utilization
  infrastructure
• Information systems applications
• Informatics Infrastructure (data, knowledge,
  services)
• Enhancing patient safety by reducing medication
  errors system-wide
• Enhancing uniform high quality by measuring
  performance to benchmark for select inpatient and
  outpatient conditions
• Expanding disease management programs by
  supporting activities for certain patients with
  chronic illnesses
• Improving cost effectiveness through managing
  utilization trends and analysis of variance

Infrastructure
Quality
Initiative Focus
Efficiency
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Clinical Systems Goals

• To ensure comparability of clinical data across
  the enterprise
• common data
• To facilitate enterprise clinical decision
  support  
• common logic
• To facilitate enterprise reporting and data
  mining
• common reports, business intelligence
• To facilitate enterprise standard clinical
  practice for providers and patients
• common workflow reduced unwarranted variation
  where appropriate
• To enhance our development agility by creating
  re-usable application components and services
• common infrastructure, 1-4 above

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Quality MattersDiabetes Measures 2006-2008
2006 Diabetes 2007 Diabetes 2008 Diabetes
Payer 1 HbA1c Screening (2x)  LDL Screening  2.8M Diabetes Composite Care (4 HEDIS tests HbA1c screening, LDL screening, Eye Exam, Nephropathy)  1.87M Develop BP baseline  935K 7 POINT SCALE 1. Diabetes Composite Care (4 HEDIS tests) 2. HbA1c Outcomes lt/ 9 3. HbA1c Outcomes lt 7 4. LDL Outcomes lt 130 5. LDL Outcomes lt 100 6. BP Outcomes lt 140/90 7. BP Outcomes lt130/80 3.15M (6,000 patients)
Payer 2 HbA1c Outcomes lt/ 9  LDL Outcomes lt 130 2.1M HbA1c Outcomes lt/ 9 1.25M  LDL Outcomes lt 100 1.25M HbA1c Outcomes lt 7 1.32M (3,100 patients)  LDL Outcomes lt 100 1.32M (3,100 patients)
Payer 3 HbA1c Screening (1X) 2.1M HbA1c Screening (1X) 1.6M (TAHP targets in negotiation) HbA1c Outcomes lt/ 9  LDL Outcomes lt 100 1.75M (2,600 patients)
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Quality Measures and RequirementsWhy is EMR
Data Necessary?

• Contractual measures are moving away from claims
  based measures to outcomes measures, which
  require clinical data elements
• E.G. Diagnoses, Lab results, Blood pressure,
  Weight, Medications, Eye exam, Ejection Fraction
• Tracking of performance and management of
  patients will be dependent upon data in EMRs
• Settlement of 2008 contractual measures will no
  longer be dependant upon claims we will need
  measure specific clinical values for all patients
  

In the longer term, there will be a move to
derive quality measures directly from the EMR,
rather than from clinically enriched
administrative data.
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Discrete vs. Shared Data, Knowledge, Logic

• Many Partners applications utilize discrete
  data, logic and knowledge or rules most are not
  integrated across sites creating islands of
  information and supporting varying levels of
  functionality.

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The Future Shared Data, Knowledge, and Logic
Partners SOA Strategy
Future clinical applications will take advantage
of shared repositories of enterprise data,
knowledge, and logic, in a services-oriented
architecture
Common Shell or Clinical Portal
Shared Logic, Dictionaries, and Rules (Enterprise
Clinical Services, Medication Services and
Knowledge Management)
Dictionaries And Rules Data (Knowledgebases)
Enterprise Repository (s) Problems, Meds,
Allergies, Labs, Orders, Notes, etc.
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Current Research Development

• Smart use of EMR Clinical Decision Support
• Quality Dashboards
• Patient Activation
• The Clinical Decision Support Consortium

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How can an EHR make a difference?
Structure
Process
Outcome
Adoption Get an EMR and use it
We are here
Meaningful Use
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Automatic Reminders
Summary Flowsheets
Intuitive Chart Summary
Coded Clinical Data
Customizable Desktop
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CAD/DM Smart Form
Smart View Data Display
Assessment, Orders, and Plan
Documentation Window
Assessment and recommendations generated from
rules engine

• Lipids
• Anti-platelet therapy
• Blood pressure
• Glucose control
• Microalbuminuria
• Immunizations
• Smoking
• Weight
• Eye and foot examinations

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Preliminary Results Smart Form On Treatment
Analysis
lt0.001
lt0.001
0.05
0.004
0.006
lt0.001
lt0.001
lt0.001
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CAD Quality Dashboard
Targets are 90th percentile for HEDIS or for
Partners providers
Red, yellow, and green indicators show adherence
with targets

• Zero defect care
• Aspirin
• Beta-blockers
• Blood pressure
• Lipids

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Discrepancy
Details
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Provider Activation
More medication changes in visits after diabetes
journal submission
Grant RW et al. Practice-linked Online Personal
Health Records for Type 2 Diabetes A Randomized
Controlled Trial. Arch Int Med 2007, in press.
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CDS Consortium Goal

• To assess, define, demonstrate, and evaluate best
  practices for knowledge management and clinical
  decision support in healthcare information
  technology at scale across multiple ambulatory
  care settings and EHR technology platforms.
• http//www.partners.org/cird/cdsc

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Six Specific Research Objectives

• Knowledge management lifecycle
• Knowledge specification
• Knowledge Portal and Repository
• CDS Knowledge Content and Public Web Services
• Evaluation
• Dissemination

1. Knowledge Management Life Cycle 1. Knowledge Management Life Cycle 1. Knowledge Management Life Cycle
2. Knowledge Specification 3. Knowledge Portal and Repository 4. CDS Public Services and Content
5. Evaluation Process for each CDS Assessment and Research Area 5. Evaluation Process for each CDS Assessment and Research Area 5. Evaluation Process for each CDS Assessment and Research Area
6. Dissemination Process for each Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area
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Thank you! Blackford Middleton,
MD bmiddleton1_at_partners.org