Testimony for the Workgroup on Computerbased Patient Records

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Testimony for the Workgroup on Computer-based
Patient Records

• NATIONAL COMMITTEE ON VITAL AND HEALTH
  STATISTICSDecember 9, 1998Presented by
  Blackford Middleton, MD, MPH, MScVice President
  for Clinical InformaticsMedicaLogic, Inc.

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Introduction

• Blackford Middleton, MD, MPH, MSc
• VP for Clinical Informatics, MedicaLogic
• Current Affiliations
• Clinical Assistant Professor of Medical
  Informatics and Outcomes Research, Oregon Health
  Sciences University, 1996-
• Attending Physician, Department of Medicine
  Faculty Practice, Providence Health System, St.
  Vincents Hospital
• Chair-person Elect, Computer-based Patient Record
  Institute (CPRI)
• Thank you for inviting me to testify before you.

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Materials Submitted

• Copy of presentation slides
• Supporting documentation
• Informatics standards used in MedicaLogic
  Logician EMR
• Logician product architecture
• Case Report Cost and Quality Benefits of an
  Electronic Medical Record in a Family Practice
  Setting

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MedicaLogic Background

• First generation EMR 1983 - ClinicaLogic
• MedicaLogic incorporated 1985
• Second generation EMR 1995 - Logician
• Open architecture, standards-based EMR
• Oracle RDBMS, TCP-IP, 2- or 3-tier architecture,
  browser-based or C desktop
• Informatics Standards
• Messaging HL-7 (hundreds of system interfaces)
• Content ICD-9-CM, CPT4, SNOMED, ASTM, LOINC,
  NDC-GPI
• Inc. 500 in 1995 (262), 1996 (181), 1997 (84),
  1998 (131) - fast growth due to standards-based
  application

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Use of Informatics Terminology Standards
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Desiderata

• Support/enhance the doctor-patient relationship
• Improve healthcare delivery efficiency, quality,
  and service at appropriate cost
• Empower clinicians with state of the art tools to
  support clinical information access and clinical
  decision making
• Exchange a longitudinal complex record between
  two disparate EMRs when a patient changes doctors
  or plans
• Secure access to healthcare information remotely
  when disease occurs away from home

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Opportunities for Annual Costs Savings with
HIT(Punk Ziegel)
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Macro-economic Benefit Cost Analysis for HIT

• US Healthcare - 1.0T, 15 of GDP
• Potential Savings Est. - 250B
• Even if HIT spending increased to 8 of
  Healthcare operating budgets - only 80B
• Therefore
• Benefit/Cost ratio 250B/80B 3.13
• Or for every 1 spent in HIT expect 3.13
  savings

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Microeconomic Analysis Capital Region Healthcare
- Concord, NH

• Family Care of Concord - 12 providers and staff
  -gt 1200 visits/month
• 42 Managed Care (seven companies), 35
  commercial insurance, 15 Medicare, 5 self pay,
  3 Medicaid
• 87,000 for hardware, software, and
  implementation of EMR with I/Fs
• Annual support costs, which include software
  maintenance fees, upgrades, information
  technology support staff, and depreciation, are
  37,000
• Total Year 1 costs 124,000

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Capital Region Healthcare - Benefits per Annum

• Transcription costs of 53,000 eliminated through
  use of physician data entry tools - net savings
  43,780
• Chart Pulls eliminated - 24,500
• Prescription writing - 71,400
• Coding research and assignment - 5,950
• Lab filing - 5,525
• Referral paperwork - 7,140
• Total Benefits 158,295

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Capital Region Healthcare - Benefits per Annum

• Qualitative Reporting - Detect true rate of
  preventive care services (discovered practice
  eligible for quality bonus)
• Drug recalls - Patient letters sent within one
  day of recall alerts
• Hospital inpatients - EMR available on hospital
  wards
• Patient Satisfaction - Group satisfaction rates
  89.9

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Capital Region Healthcare - Benefits and Costs
Summary

• Operational Costs Annual
• Total Benefits 158,295
• Total Expense 37,000
• Net Benefits 121,295
• Benefit/Cost Year 1 1.27
• Benefit/Cost Ongoing 4.27

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Q1 How do you interpret the Congressional
instruction?

• Goal Administrative Simplification
• To improve the efficiency effectiveness of the
  health care system by standardizing the
  electronic data interchange of certain
  administrative and financial transactions
• Establish penalties for non-compliance with the
  legislation and,
• To protect the security privacy of health care
  information by setting standards.
• Hopefully, through standardization of electronic
  data interchange, the system will experience a
  net savings potential over six years of 42
  billion as estimated in the 1993 WEDI Report.

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HIPAA mandate to HHS

• Adopt national standards necessary for efficient
  electronic administrative and financial health
  care transactions.
• All health plans (including government health
  plans), all clearinghouses, and those providers
  who choose to conduct their transactions
  electronically are REQUIRED to implement the
  standards.
• Provide privacy legislation.
• Provide recommendations for an electronic medical
  record.

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HIPAA mandate to HHS

• Provide standards for nine EDI administrative
  transactions (claims, encounters, enrollment,
  etc., including code sets.)
• Provide standards for COB (Coordination of
  Benefits)
• Provide standards for unique identifiers
  (including allowed uses) for individuals,
  employers, health plans, health care providers.
• Provide standards for security, confidentiality,
  and electronic signatures.

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Q2 What factors or issues are preventing or
delaying the development and widespread
implementation of uniform standards for patient
medical record information and its electronic
transmission?

• Scope
• Its a BIG and COMPLICATED problem
• Numerous stakeholders
• Unaligned incentives
• Uncoordinated healthcare standards setting
  efforts
• Poorly or un-coordinated implementation of
  vendor, or home-grown, systems
• Uncoordinated healthcare professional society
  data standardization efforts

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Q3 Is the private sector able to address these
problems? What is the role of government for
assisting the private sector in the guidance,
development, coordination, and implementation of
standards for patient medical record data and
their electronic transmission? How might the
government help to improve the standards
processes?

• Why cant vendors (private sector) solve these
  problems?
• Why cant providers solve these problems?
• Why the government should assume an expanded
  leadership role in this field?

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Why cant vendors (private sector) solve these
problems?

• Healthcare standards are DIFFERENT in character
  and scope
• tangled web of interrelated standard setting
  efforts makes broad based progress slow
• One-off solutions, or worse site-specific
  solutions
• Vendors are rewarded for successful enterprise
  implementations with little regard for
  inter-enterprise data sharing
• Possible for hard standards such as ISO stack
  protocols, HL-7
• Difficult or impossible for soft standards such
  as terminology and reference model

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Why cant providers solve these problems?

• They are not SDOs, or software developers - we
  have yet to see successful commercialization of
  home grown system.
• With rare exception provider organizations have
  little concern for data-sharing issues beyond
  their enterprise
• Often limited scope or relevance to their
  business mission (few provider organizations
  cover ALL of healthcare delivery needs)

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Why the government should assume an expanded
leadership role in this field?

• BIG problem
• Healthcare informatics standards as a public good
• Many stakeholders, unaligned incentives,
  potentially forever at odds
• Critical to the health and well being of the
  American People, and the American economy
• Leadership void identified in the 1993 GAO report
  remains unfilled

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Q 4a Which standards related to patient medical
record information and its electronic
transmission would Add the most value for
improving the quality and efficiency of health
care for the nation? Why?

• First -
• Simplify the goals to the bare minimum with
  respect to identifiers, terminology, data sets
  and models, interoperability, connectivity,
  security and confidentiality
• Second -
• Establish a framework for comprehensive health
  terminology systems, and a trusted agency to act
  as responsible party for coordinating the
  essential health information technology standards
  development process
• (Chute C, Cohn S, Campbell J et al. JAMIA
  19985503-510)

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Critical Informatics Standards and Issues

• 1. Education and training
• Public, Providers, Payers, Employers, Feds
• 2. Documentation requirements for paper and
  electronic records
• Minimal documentation requirements
• By specialty or domain
• By location of care
• 3. Minimal data sets
• Essential terminology standards for clinical
  findings pertinent to 2, and to clinical
  decision support, and outcomes assessment
• Support uniform and consistent quality measures
• CONQUEST, NCQA/HEDIS, JCAHO/Oryx

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Critical Informatics Standards and Issues

• 4. Interoperability standards for EMRs
• Identifiers person, provider, place, plan, EIN
• Enterprises already implementing MPIs
• Facilitates integration and exchange of clinical
  information
• Reference terminology and information model
• Support consistency of usage
• Support interoperability and clinical information
  exchange and machine interpretation
• Messaging - HL-7, X12, NCPDP
• NHII, secure national healthcare networks
• 5. NEW - Mandated drug interaction assessment at
  the point of care
• 6. NEW - Mandated quality standards

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Q 4b Which standards related to patient medical
record information and its electronic
transmission would Be most important to the
business or goals of your organization? Why?

• Documentation requirements (money)
• Interoperability standards - (implementation)
• Outcomes reporting -report cards (fear)
• Clinical Decision support - (quality)

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Q 4c What is the business case for more rapid
standards development and implementation?

• From whose perspective?
• FFS Provider - wait and see
• At Risk Provider Organization - Now!
• Health Plan (without owned providers) - Depends
  on local market
• Employer - ditto
• Consumer - about to explode
• Cost - Speed adoption of clinical information
  management technology to experience process
  improvements and savings
• Case study demonstrates savings utilizing fairly
  rudimentary standards
• Quality secondarily improve clinical decision
  making, and resultant outcomes

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From JAMIA

• Epidemiologist William Farr, 1848
• nomenclature is of as much importance in this
  inquiry as weights and measures in the physical
  sciences, and should be settled without delay
• Chute, et al
• Failure to achieve common goals and standards
  will preclude efficient comparison of practice
  patterns and outcomes, and we will therefore have
  great difficulty identifying best practices and
  sharing among institutions or nations. Nor would
  be be able to consistently implement identified
  best practices across institutions as health care
  deliverers begin to develop decision support
  resources...

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Q5 Do you agree with our emphasis the four focus
areas listed above? Explain.

• Four focus areas
• standards for administrative clinical messages
• standards for patient clinical information (data
  element definitions, data models, and code sets).
  
• enhance the coordination and maintenance of both
  administrative and clinically-specific code sets
  (data-dictionary and data-set registry)
• address the business case issues regarding the
  implementation of uniform data standards for
  patient medical record information.
• Yes - with additional focus on public-private
  mechanisms for production, support, and
  maintenance of informatics standards