The Value of Healthcare Information Technology in Clinical Practice

1
The Value of Healthcare Information Technology in
Clinical Practice

• Blackford Middleton, MD, MPH, MSc
• Corporate Director Clinical Informatics RD
• Chairman Center for Information Technology
  Leadership
• Partners HealthCare System, Inc.
• Assistant Professor of Medicine, Brigham
  Womens Hospital
• Harvard Medical School
• June 24, 2005

2
Learning Objectives   

• 1.    Understand basic features and functions of
  electronic health records (EHR) in clinical
  practice   
• 2.    Understand how EHRs can improve patient
  safety and the quality of care in practice   
• 3.    Understand the economic value of EHR for
  healthcare providers and other stakeholders   
• 4.    Understand how EHRs are supported by state
  and federal activities, including Regional
  Healthcare Information Organizations (RHIO)

3
Suggested Readings

• Middleton, B., Renner, K., Leavitt, M.K.. Lessons
  Learned in Deriving Benefit from Use of an
  Ambulatory Care Clinical Information Management
  System Problems and Prospects. Journal of
  Healthcare Information Management, 11497-112,
  1997.
• Audet, A.M., Doty, M., Peugh, J., Shamasdin J.,
  Zapert, K. Schoenbaum, S. Information
  Technologies When Will They Make It Into
  Physicians' Black Bags?, Medscape General
  Medicine, Dec. 7, 2004
• Johnston J, Pan E, Walker JD, Bates DW, Middleton
  B. The Value of Computerized Provider Order Entry
  in Ambulatory Settings Executive Preview Center
  for Information Technology Leadership, 2003,
  Boston, MA. http//www.citl.org/research/ACPOE.htm
  
• Wang SJ, Middleton B, Prosser LA, Bardon CG,
  Spurr CD, Carchidi PJ, Kittler AF, Goldszer RC,
  Fairchild DG, Sussman AJ, Kuperman GJ, Bates DW.
  A cost-benefit analysis of electronic medical
  records in primary care. Am J Med. 2003 Apr
  1114(5)397-403.
• Walker J, Pan E, Johnston D, Adler-Milstein J,
  Bates DW, Middleton B. The Value Of Health Care
  Information Exchange And Interoperability. Health
  Aff (Millwood). 2005 Jan 19
• Middleton B, Hammond WE, Brennan PF, Cooper GF.
  Accelerating U.S. EHR adoption how to get there
  from here. J Am Med Inform Assoc. 2005
  Jan-Feb12(1)13-9.

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Overview

• Motivation
• The Value Proposition for EHR HIT
• EHR Definition
• Making EHR Work in Practice Partners Healthcare
• QA

5
The HealthCare Industry Carefully Watches Itself
Crash
6
Healthcare Delivery Challenges

• Medical error, patient safety, quality and cost
  issues
• 1 in 4 prescriptions taken by a patient are not
  known to the treating physician
• 1 in 5 lab and x-ray tests ordered because
  originals can not be found
• Patient data unavailable in 81 of cases in one
  clinic, with an average of 4 missing items per
  case.
• 18 of medical errors are estimated to be due to
  inadequate availability of patient information.
• 40 of outpatient prescriptions unnecessary
• Patients receive only 54.9 of recommended care
• A fractured and unwired healthcare system
• Medicare beneficiaries see 1.3 13.8 unique
  providers annually, On average 6.4 different
  providers/yr
• 90 of the gt30B healthcare transactions in the US
  every year are conducted via mail, fax, or phone

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The Commonwealth Fund2003

• National survey of 1837 randomly selected U.S.
  physicians involved in direct patient care, all
  at least 3 years out of residency
• Self-administered mailed surveys
• Examined physicians current use of, future plans
  for, and perceived barriers to adopting
• EMRs
• CPOE
• Clinical decision support systems
• E-mail with other physicians and with patients

Audet, A.M., et al. Information Technologies
When Will They Make It Into Physicians' Black
Bags?, Medscape General Medicine, Dec. 7, 2004
8
The Commonwealth FundResults

• 59 of respondents use computerized access to
  lab results
• 27 of respondents use EMRs routinely or
  occasionally
• 12 receive electronic alerts about potential
  drug-prescribing problems

Audet, A.M., et al. Information Technologies
When Will They Make It Into Physicians' Black
Bags?, Medscape General Medicine, Dec. 7, 2004
9
The Commonwealth FundResults

• Top 3 barriers to adoption of IT were
• Start up costs (56)
• Lack of uniform standards (44)
• Lack of time (39)

Audet, A.M., et al. Information Technologies
When Will They Make It Into Physicians' Black
Bags?, Medscape General Medicine, Dec. 7, 2004
10
The CPR Adoption GapThe United States vs
Others
Primary Care Physician Office CPR Use by
Country, 2002
Source "European Physicians Especially in
Sweden, Netherlands, and Denmark, Lead U.S. in
Use of Electronic Medical Records." Harris
Interactive Health Care News 2(16).
11
Dilbert Wisdom
12
The Value Proposition for EHR HIT

• Headlines
• ROI of Partners Longitudinal Medical Record
• 31K Savings per provider
• Value of ACPOE suggest
• 28K savings per provider
• 44B savings potential nationally
• Value of Healthcare Information Exchange
• 78B year nationally

13
Wang SJ, Middleton B, Prosser LA, et al. Am J Med
2003 114397-403.
14
The Value of Ambulatory CPOE

• Summarized costs and benefits across clinical,
  financial, and organizational factors
• ACPOE Taxonomy
• Basic passive references, no pt data, no EDI
• Intermediate some order and Rx patient-specific
  CDSS, limited pt data, no EDI
• Advanced adv. order and Rx patient-specific
  CDSS, full patient data, with EDI
• Full-time ambulatory provider
• panel of 2,000, 3875 annual visits, capitation
  rate 11.6
• Total Rx, Lab, Radiology expenditures (almost
  1.2M)
• Rx 650K
• Lab 166K
• Radiology 355K

15
Clinical Impact of ACPOE

• Per average provider, Advanced ACPOE systems
  would prevent
• 9 ADE/yr
• 6 ADE visit/yr
• 4 ADE admission/5yr
• 3 life-threatening ADE/5yr

16
Per Average Provider Annual Cost Saving
Projections
17
5 Yr Net Cost-Benefit for 25 Providers
In Thousands
18
Advanced Systems Produce Superior Returns

• For example, Advanced ACPOE costs nearly 4x as
  much as Basic, but
• Generates over 12x more financial returns
• Produces nearly 10x greater reduction in number
  of ADEs
• Provides IT infrastructure for core clinical
  computing the outpatient EMR which produces
  additional benefits
• Pays for itself within first two years

19
National Cost Savings to Providers and Other
Healthcare Stakeholders
In US Millions
20
US Healthcare System Will Benefit

• National adoption of Advanced ACPOE systems would
  prevent
• 2 million ADE/yr
• 190,000 ADE admission/yr
• 130,000 life-threatening ADE/yr
• Nationwide implementation of advanced ACPOE
  could
• Save the US 44 billion annually

21
Value of HIEI Key Findings

• Standardized, encoded, electronic healthcare
  information exchange would
• Save the US healthcare system 337B over a
  10-year implementation period
• Save 78B in each year thereafter
• Total provider net benefit from all connections
  is 34B
• Net benefits to other stakeholders
• - Payers 22B - Pharmacies 1B
• - Laboratories 13B - Public Health 0.1B
• - Radiology centers 8B
• Dramatically reduce the administrative burden
  associated with manual data exchange
• Decrease unnecessary utilization of duplicative
  laboratory and radiology tests

Walker, J et al Health Aff 2005 Jan 19
22
HIEI Definition

• Provider-centric encounter-based model of
  clinical information exchange

• Clinical and administrative transactions and data
  exchange
• Between providers and other providers
• Between providers and labs, pharmacies, payers,
  radiology centers, and public health departments

Public Health
Other Provider
Radiology
Provider
Pharmacy
Payer
Laboratory
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HIEI Taxonomy
No PC/information technology
Fax/Email
Structured messages, non-standard content/data
Structured messages, standardized content/data
24
HIEI National Net Cost-Benefit
Level 2
Level 3
Level 4
Value of HIE standards is the difference between
Level 3 4
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10-Year Cumulative Net Return by HIEI Level
Level 4
in billions
26
US Would Benefit from Healthcare Information
Exchange

• Nationwide implementation of standardized
  healthcare information exchange would
• Save 337B over 10 years
• Save the US 78B annually at steady state
• Cumulative breakeven during year five of
  implementation
• There is a business case for standardized
  healthcare information exchange and
  interoperability

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EHR Definition

• Wikipedia Free Encyclopedia http//en.wikipedia.
  org
• An electronic health record (EHR) is a medical
  record and any other information relating to the
  past, present or future physical and mental
  health, or condition of a patient which resides
  in computers which capture, transmit, receive,
  store, retrieve, link, and manipulate multimedia
  data for the primary purpose of providing health
  care and health-related services.

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Critical EHR Functions

• Core Functionalities for an Electronic Health
  Record System
• Results Management
• Health Information and Data
• Order Entry/Management
• Decision Support
• Electronic Communication and Connectivity
• Patient Support
• Administrative Processes
• Reporting Population Health Management

Tang PC, and the IOM Committee on Data Standards
for Patient Safety. Letter Report Key
Capabilities of an Electronic Health Record
System. Institute of Medicine, July, 2003.
30
Results Management

• At a minimum, results management refers to the
  presentation of laboratory and other data
  gathered from ancillary services to the provider
  in the clinical care environment.
• Advanced systems may organize results by
  specialty or discipline, and include results
  alerting, graphing/trending, communication to
  patient

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
31
Health Information and Data

• The EHR includes the patients current medical
  problems and conditions, current medications,
  current allergies, and advance directives, as
  well as electronic documentation from clinical
  encounters or patient care contacts

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
32
Order Entry/Management

• The EHR allows entry of prescriptions, laboratory
  tests and procedures, referrals, charge capture
  and may print order requisition, or transmit
  electronically to laboratory provider.
• Advanced systems track order status, preliminary
  results, and note order closure

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
33
Decision Support

• EHRs support writing an electronic prescription
  and generate alerts about potential allergies,
  drug-drug interactions, drug and laboratory
  interactions, and a patients symptom profile.

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
34
Electronic Communication and Connectivity
Clinical Encounter
Diagnosis
Treatment
Claims and Billing
Public Health
35
Patient Support

• The EHR should facilitate providing patient care
  handouts to patients or their family on current
  medications, medical problems and conditions,
  tests and procedures.
• These patient care handouts facilitate
  doctor-patient communication and support patient
  education.

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
36
Administrative Processes

• EHRs are usually distinct from financial
  information management systems, with interfaces
  for the exchange of clinical and financial
  information as appropriate for patient
  accounting.
• An interface engine can facilitate the exchange
  of clinical information to the practice
  management system for the purpose of creating the
  patients bill.

Rx
Claims
EHR
External Systems/ Internet
PMS

Content
CRO
Gateway



LAN
PMS


EHR


Nursing Station

Exam Room/

Front Desk
Office

Middleton B. The Value of Electronic Health
Records. Chapter to appear in HealthePeople,
Kolodner R, Demetriedes J. Eds.
37
Reporting Population Health Management

• EHR systems allow for reporting on the patient
  care database.
• Reports may examine how well a population of
  diabetics are being managed against clinical
  benchmarks, or what fraction of women of
  appropriate screening age have had mammography,
  for example.

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The Role of Informatics Standards Henry SB,
Lenert L, Middleton B, HIMSS Proc, pp. 57-81,
1993.
Measurement
Clinimetrics, Reliability, Bias, Error
Data
Vocabulary
Message HL-7 2.X, LOINC, ASTM, IEEE-Medix
MIB Model Ref Info Model, Clinical Doc.
Architect., Knowledge Arden, GLIF
ICD-9-CM, CPT, ASCx12N, NCPDP, RxNORM,
NANDA, SNOMED
Analysis
EMR
Risk profiling, Disease Management, Quality
Performance
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Partners HealthCare NHII in situ

• Founded in 1994
• Brigham and Womens Hospital
• Massachusetts General Hospital
• Now includes
• Community Physician Network
• 2 Rehab Hospitals
• 4 Community Hospitals
• Affiliated cancer hospital Dana Farber
• Common Clinical IT supported by Partners
  Information Systems

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Partners Geography
Salem Shaughnessy Kaplan
Partners Acute Hospitals
Union
Partners Specialty Hospitals
McLean
Spaulding
Towns With PCHI Primary Care Care Physician
Practices
MGH
Newton- Wellesley
BWH
Faulkner

RHCI
Orleans
Go Red Sox!
41
Overview of Partners IS Scale of the Integration
Effort

• 55,000 devices attached to the Partners network
• 35,000 users accounts
• 110 locations on the network
• 750 servers
• 800 applications
• 540 active projects
• 1,100 employees based in 19 locations
• FY05 submitted capital budget of 39M
• FY05 operating budget of 125M

42
Partners HIT Statistics

• Total number of patients 3,300,000
• Orders entered daily inpatient CPOE 26,000/d
• Notes in LMR 9,937,947
• Medications 2,661,475
• Appointments Avg./day 17,000
• New Notes Avg./day 15,000
• Patient Sessions Avg./day 220,000
• Telemedicine consultations annually 2,600
• Patient users of the patient-provider
  portal 20,000

43
Intuitive Chart Summary
Automatic Reminders
Summary Flowsheets
Coded Clinical Data
Customizable Desktop
44
Automatic Alerts in the Clinical Workflow
45
KnowledgeLink in the Workflow
46
Patient Name
Patient Name
Results Management and Patient Communication
47
Checking results, writing letters
48
Information Access ? Knowledge Linking
49

• Mail
• (secure)

• Medications
• Allergies
• (from LMR)

• Mail settings
• Notification
• Request Defaults
• Pharmacy
• Contact info
• Registration info

• Prescription
• Appointment
• Referral
• (practice selected)

• Staff
• Directions
• Insurance
• Contact Information
• (practice specific)

• Illnesses Conditions
• Drugs
• Medical Tests
• Self Help
• (from Healthwise)

50
Patient Disease Management
51
From Clinic to IDN to RHIO to NHII
52
Accelerating US EHR Adoption

• Financial Incentives to Stimulate EHR Marketplace
• Reimbursement reform
• Capital availability
• EHR Certification and Accreditation
• HIT Standard Setting
• Specify essential standards for EHR (data,
  messaging, reference architecture)
• Specify a minimal clinical data set
• Specify minimal functional standards for HIT
  systems
• Enabling Policy
• Relaxation of Stark (MMA)
• Establish federal policy on clinical data
  ownership and stewardship
• Establish policy framework for Regional
  Healthcare Information Authorities
• Establish U.S. National licensure in the health
  professions
• Educational, Marketing, and Supporting Activities
• Establish educational and marketing campaign for
  the public "Got EHR?"
• Establish educational campaign for health
  professionals
• Establish educational campaign for healthcare
  management
• Create a National Healthcare Information
  Technology Resource Center

Middleton B et al. JAMIA Oct 2004
53
Where Are We?
54
I conclude that though the individual physician
is not perfectible, the system of care is, and
that the computer will play a major part in the
perfection of future care systems. Clem
McDonald, MD NEJM 2951355, 1976

• Thank you!
• Blackford Middleton, MD
• bmiddleton1_at_partners.org

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Glossary of Abbreviations